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NATIONAL LIBRARY OF MEDICINE 
Bethesda, Maryland 







«* 






tfrfwu&i^ 





J 



FIRST LINES 



OF THE 



PRACTICE OF PHYSIC 



WILLIAM CULLEN, M. D. 

LATE PROFESSOR OF THE PRACTICE OF PHYSIC IN THE 
UNIVERSITY OF EDINBURGH, &C. 



WITH PRACTICAL AND EXPLANATORY 
NOTES, 

BY JOHN BOTHER J M, M. D. 



IN TWO VOLUMES. 



VOL. I. 



NEW-YORK 



PRINTED BY L. NICHOLS, 
FOR I. RILEY & Co. BOOK-SELLERS & STATIONERS, 

NO 1, CITY-HOTEL, BROADWAY. 



1805. 



Artonytnoufe 



CONTENTS 



OF THE 



FIRST VOLUME. 



Preface 

Introduction 



CHAP. L 
CHAP. II. 
CHAP. III. 
CHAP.. IV. 
CHAP. V. 
CHAP. VI. 

Sect. I. 

Sect. II. 



CHAP. I. 

Sect. I. 

Sect. II. 

Sect. III. 

Sect. IV. 

Sect. V. 
CHAP. II. 
CHAP. III. 
CHAP. IV. 
CHAP. V. 

Sect. I. 

Sect. II. 

Sect. III. 

Sect, IV. 

Sect. V. 
CHAP. VI. 



PART I. 

Of Pyrexia, or Febrile Diseases 

BOOK I. 

Of Fevers 

Of the Phenomena of Fevers 

Of the proximate cause of Fevers 

Of the Difference of Fevers, and its Causes* 

Of the remote causes of Fevers 

Of the Prognosis of Fevers 

Of the Method of Cure in Fevers 

Of the Cure of Continued Fevers 

Of the Cure of Intermittent Fevers 

BOOK II. 

Of Inflammations, or Phlegmasis 

Of Inflammation in general 

Of the Phenomena of Inflammation 

Of the Proximate Cause of Inflammation 

Of the Terminations of Inflammation 

Of the Remote Causes of Inflammation 

Of the Cure of Inflammation 

Of Inflammation, more strictly Cutaneous 

Of Ophthalmia, or Inflammation of the Eye 

Of Phrenzy, or Phrenitis 

Of the Quinsy, or Cynanche 

Of the Cynanche Tonsillaris 

Of the Cynanche Maligna 

Of the Cynanche Trachealis 

Of the Cynanche Pharyngea 

Of the Cynanche Parotidaa 

Of Pneumonic Inflammation 



PAGE 

V 

2S 



24 



25 
ibid 
31 
40 
46 
54 
61 
ibid 
8S 



91 
ibid 
ibid 
92 
97 
101 
102T 
106 

ioa 

IIS 
115" 
ibid 
117 

m 

124 
ibid 
12& 



CONTENTS. 



CHAP. VII. Of the Peripneumonia Not ha, or Bastard Peri- 

pneumony 
CHAP. VIII. Of the Gastritis, or Inflammation of the Stomach 
CHAP. IX. Of the Enteritis, or Inflammation of the Intestines 
CHAP. X. Of the Hepatitis, or Inflammation of the Liver 
CHAP. XL Of the Nephritis, or Inflammation of the Kidneys 
CHAP. XII. Of the Rheumatism 
CHAP. XIII. Of theToothach, or Odontalgia 
CHAP. XIV. Of the Gout 

BOOK in. 

Of Exanthemata, or Eruptive Fevers 
CHAP. I. Of the Small-pox 

CHAP. II. Of the Chicken-pox 
CHAP. III. Of the Measles 
CHAP. IV. Of the Scarlet Fever 
CHAP.V. Of the Plague 

Sect. I. Of the Phenomena of the Plague 

Sect. II. Of the Prevention of the Plague 

Sect. III. Of the Cure of the Plague 
CHAP. VI. Of Erysipelas, or Sl Anthony's Fire 
CHAP. VII. Of the Miliary Fever 

CHAP. VIII. Of the remaining Exanthemata : Urticaria, Pem- 
phigus, and Aphtha 

BOOK IV. 

Of Hemorrhagies 
CHAP. I. Of Hemorrhagy in general 

Sect. I. Of the Phenomena of Hemorrhagy 

Sect. II. Of the Proximate Cause of Hemorrhagy 

Sect. III. Of the Remote Causes of Hemorrhagy 
Sect. IV. Of the Cure of Hemorrhagy 
CHAP. II. Of the Epistaxis, or Hemorrhagy of the Nose 
CHAP. III. Of the Hemoptysis, or Hemorrhagy from the Lungs 263 
Sect. I. Of the Phenomena and Causes of Hemoptysis ibid 

Sect. II. Of the Cure of Hemoptysis 267 

CHAP. IV. Of the Phthisis Pulmonalis, or Consumption of the 

Lungs 269 

Sect. I. Of the Phenomena and Causes of the Phthisis 

Pulmonalis ibid 

Sect. II. Of the Cure of Phthisis 284 

CHAP. V. Of the Hemorrhois, or of the Hemorrhoidal Swell- 
ing and Flux 290 
Sect. I. Of the Phenomena and Causes of the Hemorrhois ibid 
Sect. II. Of the Cure of Hemorrhoidal Affections 295 



139 
143 
148 
149 
153 
155 
164 
168 



194 

195 
211 
ibid 
216 
220 
ibid 
222 
225 
227 
230 

233 



238 
ibid 
239 
240 
250 
251 
258 



PREFACE. 



TO deliver a System of the Doctrines and Rules proper for 
directing the Practice of Physic, is an undertaking that 
appears to me to be attended with great difficulty ; and after an 
experience of more than forty years in that practice, as well as 
after much reading and reflection, it was with great diffidence 
that I ever entered upon such a work. It was, however, what 
seemed to be my duty as a Professor that induced me to make 
the attempt ; and I was engaged in it by the same sentiments 
that the illustrious Dr. Boerhaave has expressed in the following 
passage of the preface to his Institutions : " Simul enim do- 
cendo admotus eram sensu, propriorum cogitatorum explicatione 
docentem plus proficere, quam si opus ab alio, conscriptum in- 
terpretari suscipit. Sua quippe optime intelligit, sua cuique prsB" 
caeteris placent, unde clarior fere doctrina, atque animata ple- 
rumque sequitur oratio. Qui vero sensa alterius exponit, infe- 
licius saepenumero eadem assequitur ; quumque suo quisque sen- 
su abundat, multa refutanda frequenter invenit, unde gravem 
frustra laborem aggravat, minusque incitata dictione utitur." 
It is well known, that a Text-book is not only extremely useful, 
but necessary to Students who are to hear Lectures ; and from 
the same considerations that moved Dr. Boerhaave, I also wish- 
ed to have one for myself; while at the same time, from some 
peculiar circumstances in my situation, I had some additional 
inducements to undertake such a work. 

Before I was established as Professor of the Practice of Physic 
in this University, I had been employed in giving Clinical Lec- 
tures in the Royal Infirmary ; and upon that occasion had deli- 
vered, what, in my own opinion, seemed most just with regard 
to both the nature and the cure of the diseases of which I had 
occasion to treat. But I soon found, that my doctrines were 
taken notice of, as new, and peculiar to myself ; and were ac- 
cordingly severely criticised by those who, having long before 
been trained up in the system of Boerhaave, had continued to 
think that that system neither required any change, nor admitted 
of any amendment. I found, at the same time, that my doc- 
trines were frequently criticised by persons who either had not 
been informed of them correctly, or who seemed not to under- 
stand them fully ; and therefore, as soon as I was employed to 

B 



vi PREFACE. 

teach a more complete system of the Practice of Physic, I judg- 
ed it necessary to publish a Text-book, not only for the benefit of 
my hearers, but that I might also have an opportunity of obtain- 
ing the opinion of the public more at large, and thereby be en- 
abled either to vindicate my doctrines, or be taught to correct 
them. These were the motives for my attempting the volumes 
I formerly published ; and now from many years experience of 
their utility to my hearers, as well as from the favorable recep- 
tion they have met with from the public, I am induced to give a 
, new edition of this Work, not only, as I hope, more correct in 
many parts, but also more complete and comprehensive in its 
general extent. 

At the first publication of this work, it was intended chiefly 
for the use of those gentlemen who attended my lectures ; altho' 
even then for the reasons I have mentioned, it was rendered 
more full than text-books commonly are ; and, in the repeated 
editions I have since had occasion to give, I hive been constantly 
endeavoring to render it more full and comprehensive. In these 
respects, I hope the present edition will appear to be rendered 
more fit for general use, and better calculated to afford satisfac- 
tion to all those who think they may still receive any instruction 
from reading on this subject. 

While I thus deliver my work in its now more improved state, 
with the hopes that it may be of use to others as well as to those 
who hear my Lectures, I must at the same time observe, that it 
presents a system which is in many respects new, and therefore I 
apprehend it to be not only proper, but necessary, that I should 
explain here upon what grounds, and from what considerations, 
this has been attempted. 

In the first place, I apprehend that, in every branch of sci- 
ence with respect to which new facts are daily acquired, and these 
consequently giving occasion to new reflections, which correct 
the principles formerly adopted, it is necessary from time to 
time, to reform and renew the whole system, with all the addi- 
tions and amendments which it has received and is then capable 
of. That at present, this is requisite with regard to the Science 
of Medicine, will, I believe, readily occur to every person who 
at all' thinks for himself, and is acquainted with the Systems 
which have hitherto prevailed. While, therefore, I attempt 
this, I think it may be allowable, and upon this occasion even 
proper, that I should offer some remarks on the principal Sys- 
tems of Medicine which have of late prevailed in Europe, and 
that I should take notice of the present state of Physic as it is 
influenced by these. Such remarks, I hope, may be of some 
use to those, who attempt to improve their knowledge by the 
reading of books. 



PREFACE. vii 

Whether the practice of Physic should admit of reasoning, or 
be entirely rested upon experience, has long been, and may still 
be, a matter of dispute. I shall not, however, at present, enter 
upon the discussion of this ; because I can venture to assert, 
that, at almost all times, the practice has been, and still is, 
with every person, founded more or less, upon certain princi- 
ples established by reasoning ; and therefore, in attempting to 
offer some view of the present state of Physic, I must give an 
account of those systems of the principles of science which have 
lately prevailed, or may be supposed still to prevail in Europe. 

When, after many ages of darkness, which had destroyed 
almost the whole of ancient literature, learning was again re- 
stored in the fifteenth century ;* so from causes which are well 
known, it was the system of Galen alone that the Physicians of 
those days became acquainted with ; and during the course of 
the sixteenth century, the study of Physicians was almost solely 
employed in explaining and confirming that system. Early, in- 
deed, in the sixteenth century, the noted Paracelsusf had laid 
the foundation of a Chemical system which was in direct oppo- 
sition to that of Galen ; and, by the efficacy of the medicines 
employed by Paracelsus and his followers, their system came to 
be received by many : but the systematic Physicians continued 
to be chiefly Galenists, and kept possession of the Schools till 
the middle of the seventeenth century. It is not, however, 
necessary here to enter into any further detail respecting the fate 
of those two opposite sects ; for the only circumstance concern- 
ing them, which I would at present point out, is, that in the writ- 

* At this period the medical knowledge of Europe was chiefly, and indeed solely, such as had 
been derived from the Arabians. At the conquest of Constantinople by the Turks, about the 
middle of the fifteenth century, several of the Greeks fled into Italy, and the people of Europe 
communicating with them, found them to be intelligent, and some of them even learned men j 
the Europeans weie thence led to study the Greek language, in order to read the valuable 
books which these fugitives had so much extolled ; and among other works, those of Galen 
particularly attracted the notice of the physicians, which to their great astonishment, contained 
all the medical knowledge that had been attributed to the Arabians, To the Greek writers, 
therefore, the physicians of those tr.nes closely applied their attention, thinking these books the 
only true fountains of medical knowledge ; and thus it was that the Galenical doctrines be- 
came prevalent all over Europe. 

+ The remarkable circumstances in the life of Aureolus Philippus Theophrattus Bombasius 
ParastUus J< too numerous for insertion in the narrow li- 

mits alio use of lmh lien, about two German miles 

from Zurick, in the year 14 l »3. At three years old he was made an eunuch by an accident. He 
travelled ail over the continent of Europe, obtaining knowledge in chemistry and physic, and 
then travelled about the country practising what he had learned. His chief remedies were 
opium and mercury, and liis great success increased his celebrity. He cured the famous printer 
Frobmiui of Basil of an inveterate disease ; this cure brought him acquainted with Erasmus, 
and made him known to the magistracy of Basil, who elected him proressor in 15'-'7. He lec- 
tured two hours everv day. While seated in his chair, he burnt with great solemnity, the writ- 
ings of Galen and Avicenna ; and declared to his audience, that if God would not impart the 
secrets of physic, it was not only allowable, but even justifiable to consult the devil. He soon 
left Basil, and continued 10 ramble about the country, generally intoxicated, and never chang- 
ing his ootids, or even going to bed. He died after an illness of a few days, in an inn at Salti- 
burgh. in 1541, in his 48th year, tho' he had promised himself that, by the use of his elixir, he 
tuoulu live to the a^e of Methusalem. 



viii PREFACE. 

ings of both, the explanations they severally attempted to give 
of the phenomena of health or sickness, turned entirely upon 
the state of the fluids of the body. 

Such was the state of the science of physic till about the mid- 
dle of the seventeenth century, when the circulation of the blood 
came to be generally known and admitted ; and when this, to- 
gether with the discovery of the receptacle of the chyle, and of 
the thoracic duct, finally exploded the Galenic system. About 
the same period a considerable revolution had taken place in the 
system of Natural Philosophy. In the course of the seventeenth 
century, Galileo had introduced mathematical reasoning ; and 
Lord Bacon having proposed the method of induction, had 
thereby excited a disposition to observe facts, and to make ex- 
periments. These new modes of philosophizing, it might be 
supposed, would soon have had some influence on the state of 
medicine ; but the progress of this was slow. The knowledge 
of the Circulation did indeed necessarily lead to the consideration 
as well as to a clearer view of the Organic System in animal bo- 
dies ; which again led to the application of the mechanical phi- 
losophy towards explaining the phenomena of the animal oecono- 
my ; and it was applied accordingly, and continued, till very 
lately, to be the fashionable mode of reasoning on the subject. 
Such reasoning, indeed, must still in several respects continue 
to be applied : but it would be easy to show, that it neither 
could, nor ever can be, applied to any great extent in explain- 
ing the animal ceconomy ; and we must therefore look for other 
circumstances which had a greater share in modelling the system 
of Physic. 

With this view, it may be remarked, that till the period just 
now mentioned, every Physician, whether Galenist or Chemist, 
had been so much accustomed to consider the state and condi- 
tion of the fluids, both as the cause of disease, and as the foun- 
dation for explaining the operation of medicines, that what we 
may term an humoral pathology still continued to make a 
great part of every system. In these circumstances, it was soon 
perceived, that chemistry promised a much better explanation 
than the Galenic or Aristotellian philosophy had done ; and, 
therefore, while the latter was entirely laid aside, a chemical 
reasoning was every where received. Lord Bacon with his usual 
sagacity, had early observed, that chemistry promised a great 
number of facts, and he thereby gave it credit ; whilst the 
Corpuscularian philosophy, restored by Gassendi, readily united 
with the reasonings of the Chemists ; and the philosophy of Des 
Cartes readily united with both. From all these circumstances, 
an Humoral, and chiefly a Chemical Pathology, came to pre- 
vail very much till the end of the last century ; and has indeed, 



PREFACE. ix 

continued to have a great share in our systems down to die pre- 
sent time. 

It is proper now, however, to observe, that about the begin- 
ning of the present century, when every part of science came to 
be on a more improved and correct footing, there appeared in 
the writings of Stahl, of Hoffman, and of Boerhaave, three 
new, and considerably different, Systems of Physic ; which have 
ever since had a great share in directing the practice of it. In 
order, therefore, to give a nearer view of the present state of 
Physic, I shall offer some remarks upon these different systems ; 
endeavoring to point out the advantages, as well as the disad- 
vantages of each, and how far they still prevail ; or, according 
to my judgment, deserve to do so. 

I shall begin with considering that of Dr. Stahl, which I 
think appeared first, and for a long time after was the prevail- 
ing system in Germany. 

The chief and leading principle of this system is, that the ra- 
tional soul of man governs the whole oeconomy of his body. At 
all times, Physicians have observed, that the animal oeconomy 
has in itself a power or condition, by which, in many instances, 
it resists the injuries which threaten it ; and by which it also, on 
many occasions, corrects or removes die disorders induced, or 
arising in it. This power, Physicians very anciently attributed, 
under a vague idea, to an agent in the system, which they call- 
ed nature ; and the language of a vis conservatrix et medicairix 
natura, has continued in the schools of medicine from the most 
ancient times to the present. 

Dr. Stahl has explicitly founded his system on the supposition 
that the power of nature, so much talked of, is entirely in die ra- 
tional soul. He supposes, that upon many occasions, the soul 
acts independently of the state of the body ; and that, without 
any physical necessity arising from that state, the soul, purely 
in consequence of its intelligence perceiving the tendency of nox- 
ious powers threatening, or of disorders any wise arising in die 
system, immediately excites such motions in the body as are 
suited to obviate the hurtful or pernicious consequences which 
might otherwise take place. — Many of my readers may think it 
was hardly necessary for me to take notice of a system founded 
upon so fanciful an hypothesis ; but there is often so much seem- 
ing appearance of intelligence and design in the operations of the 
animal oeconomy, that many eminent persons, as Perrault in 
France, Nichols and Mead in England, Porterfield and Simson in 
Scotland, and Gaubius in Holland, have very much counten- 
anced the same opinion, and it is therefore certainly entitled to 
some regard. It is not, however, necessary for me here to en- 
ter into any refutation of it. Dr. Hoffman has done this fully, 



x PREFACE. 

in his Commentarius de differentia inter Hoffmanni doctrinam medico- 
mechanicam et G. E. StahTti medico-organicam ; and both Boerhaave 
and Haller, though no favorers of materialism, have mentioned 
a doctrine very opposite to that of Stahl. 

In my Physiology I have offered some arguments against the 
same ; and I shall only add now, that whoever considers what 
has been said by Dr. Nichols in his Oratio de Anima Medica, and by 
Dr. Gaubius in some parts of his Pathology, must perceive, that 
the admitting of such a capricious government of the animal ceco- 
nomy, as these authors in some instances suppose, would at once 
lead us to reject all the physical and mechanical reasoning we 
might employ concerning the human body. Dr. Stahl himself 
seems to have been aware of this ; and therefore in his preface to 
Juncker's Conspectus Therapeia Specia/is, has acknowledged, that 
his general principle was not at all necessary ; which is in effect 
saying that it is not compatible with any system of principles that 
ought to govern our practice. Upon this footing, I might have 
at once rejected the Stahlion principle : but it is even dangerous 
to bring any such principle into view ; for, after all Dr. Stahl had 
said in a passage just now referred to, I find, that, in the whole 
of their practice, both he and his followers have been very much 
governed by their general principle. Trusting much to the con- 
stant attention and wisdom of nature, they have proposed the 
Art of curing by expectation ; have therefore, for the most part, 
proposed only very inert and frivolous remedies ; have zealously 
opposed the use of some of the most efficacious, such as opium 
and the Peruvian bark ; and are extremely reserved in the use of 
general remedies, such as bleeding, vomiting, &c. 

Although these remarks, upon a system which may now be 
considered as exploded or neglected, may seem superfluous ; I 
have been willing to give these strictures on the Stahlion system, 
that I might carry my remarks a little farther, and take this op- 
portunity of observing, that, in whatever manner we may explain 
what have been called the operations of nature, it appears to me, 
that the general doctrine of Nature curing diseases, the so much 
vaunted Hippocratic method of curing, has often had a baneful in- 
fluence on the practice of physic ; as either leading physicians in- 
to, or continuing them in, a weak and feeble practice ; and at the 
same time superseding or discouraging all the attempts of art. 
Dr. Huxham has properly observed that even in the hands of Sy- 
denham it had this effect. Although it may sometimes avoid 
the mischiefs of bold and rash practitioners, yet it certainly pro. 
duces that caution and timidity which have ever opposed the in- 
troduction of new and efficacious remedies. The opposition to 
chemical medicines in the sixteenth and seventeenth centuries, and 
the noted condemnation of Antimony by the Medical Faculty of 



PREFACE. xi 

Paris, are to be attributed chiefly to those prejudices, which the 
physicians of France did not entirely get the better of for near an 
hundred years after. We may take notice of the reserve it pro- 
duced in Boerhaave, with respect to the use of the Peruvian 
bark. We have had lately published, under the title Constitut tones 
Epidemic*, notes of the particular practice of the late Baron Van 
Swieten ; upon which the editor very properly observes, That the 
use of the bark, in intermitting fevers, appears very rarely in that 
practice ; and we know very well where Van Swieten learned 
that reserve. 

I might go farther, and show how much the attention to the 
Autocrateia, allowed of, in one shape or other, by every sect, has 
corrupted the practice among all physicians, from Hippocrates to 
Stahl. It must, however, be sufficiently obvious, and I shall con- 
clude the subject with observing, that although this vis medicatrix 
nature, must unavoidably be received as a fact ; yet whether it is 
admitted, it throws an obscurity upon our system ; and it is only 
where the impotence of our art is very manifest and considerable, 
that we ought to admit of it in practice. 

To finish our remarks upon the Stahlion System, I shall shortly 
observe, that it did not depend entirely upon the Autocrateia, but 
also supposed a state of the body and diseases, that admitted of re- 
medies ; which, under the power and direction of the soul, acted 
upon the organization and matter of the body, so as to cure its 
diseases. Upon this footing, the Stahlion pathology turned en- 
tirely upon Plethora and Cacochymy. It was with respect to the 
former that they especially applied their doctrine of the Autocra- 
teia in a very fantastical manner ; and, with respect to the latter, 
they have been involved in a humoral pathology as much as the 
systematic physicians who had gone before them, and with a the- 
ory so incorrect as not to merit the smallest attention. After all, 
I ought not to dismiss the consideration of the Stahlion system, 
without remarking, that as the followers of this system were very 
intent upon observing the method of nature, so they were very 
attentive in observing the phenomena of diseases, and have givcto 
us in their writings many facts not to be found elsewhere. 

While the doctrines of Stahl were prevailing in the university 
of Halle, Dr. Hoffman,* a professor in the same university pro- 
posed a system that was very different. He received into his sys- 
tem a great deal of the mechanical, Cartesian, and chemical doc- 

♦ Frederick Hoffman was born at Halle in the year 1660. He graduated in 1681 ; was made 
profe^r o ph"°cXre in the year 1693 , and filled that chair till his death in 1742. A very re- 
markable ci&umstance of his life is, that he never took fees from his pat.en s, but was con tent 
with his stipend He was in high repute as a practitioner, and curing the Lmperor Charles VI. 
Sd Empffind Frederick I. Sf PnTssia, of iterate .dtelgJiBmi fi&Eflfi&i 
His works are collected into six volumes, folio, published at different times from 1/48 to luS*. 
They abound with many useful practical directions ; but at die same time coutain many Invo- 
tsus remarkj, and an abundance of conjectural theory. 



xii PREFACE. 

trines of the systems .which had appeared before : but with re- 
spect to these, it is of no consequence to observe in what manner 
he modified the doctrines of his predecessors, as his improvements 
in these respects were no ways considerable, and no part of them 
now remain ; and the real value of his works, beyond what I am 
just now going to mention, rests entirely on the many facts 
they contain. The merit of Dr. Hoffman and of his works is, 
that he made, or rather suggested, an addition to the system, 
which highly deserves our attention. Of this I cannot give a 
clearer account than by giving it in the author's own words. In 
his Medic'ina Rationalis Systematica, Tom III. § 1. chap. iv. he 
has given his Gcnealogia morborum ex turbato solidorum et jluidorum 
mechanismo ; and in the 47th and last paragraph of this chapter 
he sums up his doctrine in the following words : " Ex hisce au- 
tem omnibus uberius hactenus excussis, per quam dilucide ap- 
parere arbitror, quod solus spasmus et simplex atonia, ssquabi- 
lem, liberum, ac proportionatum sanguinis omnisque generis flui- 
dorum motum, quibiis excretionum successuset integritas functi- 
onum animi et corporis proxime nititur, turbando ac pervertendo, 
universam vitalem ceconomiam subruant ac destruant ; atque hinc 
universa pathologia longe rectius atque facilius ex vitio motuum 

MICROCOSMICORUM IN SOL1DIS, quam EX VARUS AFFECTIONI- 

bus vitiosorum humorum, deduci atque explicari possit, adeo- 
que omnis generis asgritudines internas, ad praeternaturalis 
generis nervosi affectiones sint referendos. Etenim lassis 
quf cunque modo, vel nervis per corpus discurrentibus, vel mem- 
branosis quibusvis nervosis partibus, illico motuum anomalias, 
modo leviores, modo graviores subsequuntur. Deinde attenta 
observatio docet, motus quosvis morbosos principaliter sedem fi- 
gere et tyrannidem exercere in nervosis corporis partibus, cujus 
generis praeter omnes canales,qui systaltico et diastaltico motu pol- 
lentes, contentos succos tradunt, universum nimirum intestinorum 
et ventriculi ab cesophago ad anum canalem, totum sy sterna vaso- 
rura arteriosorum, ductuum biliariorum, salivalium, urinariorum 
et subcutaneorum, sunt quoque membranae nerveo-musculares ce- 
rebri et medullas spinalis, praesertim haec, quae dura mater vocatur, 
organis sensoriis obductae, nee non tunicas illse ac ligamenta, quae 
ossa cingunt artusque firmant. Nam nullus dolor, nulla inflamma- 
tio, nullus spasmus, nulla motus et sensus impotentia, nulla febris 
humoris illius excretio, accidit, in qua non has partes patiantur. 
Porro etiam omnes, quas morbos gignunt causae, operationem su- 
am potissimam perficiunt in partes motu et sensu prasditas, et ca- 
nales ex his coagmentatos, eorum motum, et cum hoc fluidorum 
cursum, pervertendo ; ita tamen, ut sicuti varias indolis sunt, sic 
etiam varie in nerveas partes agant, iisdemque noxam affiricent. 
Demum omnia quoque eximiae virtutis medicamenta, non tam 



PREFACE. xiii 

in partes fluidas, earum crasin ac intemperiem corrigendo, quam 
potius in solidas et nervosas, earundem motus alterando ac mode- 
rando, suam edunt operationem ; De quibus tamen omnibus, in 
vulgari usque eo recepta morborum doctrina, altum est silentium.'* 

It is true, that Dr. Willis* had laid a foundation for this doc- 
trine, in his Patholog'ia Cerebri et Nervorum ; and Baglivi had pro- 
posed a system of this kind in his Specimen dejibra motrici et morbosa. 
But in these writers it was either not extensively applied to dis- 
eases, or was still so involved in many phisiological errors, that 
they had attracted little attention ; and Dr. Hoffman was the 
first who gave any tolerable simple and clear system on the sub- 
ject, or pointed out any extensive application of it to the explana- 
tion of diseases. 

There can be no sort of doubt that the phenomena of the ani- 
mal ceconomy in health and in sickness, can only be explained by 
considering the state and affections of the primary moving pow- 
ers in it. It is to me surprising that physicians were so long in 
perceiving this, and I think we are particularly indebted to Dr. 
Hoffman for putting us into the proper train of investigation j 
and it every day appears that Physicians perceive the necessity of 
entering more and more into this inquiry. It was this, I think, 
which engaged Dr. Kaaw Boerhaave to publish his work entitled 
Impetumfaciens ; as well as Dr. Gaubius to give the Pathology of 
the Solidum vivum. Even the Baron Van Swieten has upon the 
same view thought it necessary, in at least one particular, to 
make a very considerable change in the doctrine of his master, as 
he has done in his Commentary upon the 775th Aphorism. Dr. 
Haller has advanced this part of science very much by his experi- 
ments on irritability and sensibility. In these and in many other 
instances, particularly in the writings of Mr. Barthez of Mont- 
pelier, of some progress in the study of the affections in the Ner- 
vous System, we must perceive how much we are indebted to 
Dr. Hoffman for his so properly beginning it. The subject, how- 
ever, is difficult : the laws of the Nervous System, in the various 
circumstances of the animal ceconomy, are by no means ascer- 
tained ; and from want of attention and observation with the view 
to a system on this subject, the business appears to many as an in- 
explicable mystery. There is no wonder therefore, that on such a 
difficult subject, Dr. Hoffman's system was imperfect and incor- 
rect ; and has had less influence on the writings and practice of 
Physicians since his time, than might have been expected. He 

* This illustrious physician was born at great Bedwin in Wiltshire in 1621. He took the de- 
gree of master of arts in 1642 at Oxford, where he was made professor of natural philosophy in 
lUk) : and thut same year he took the degree of M. D. His practice was extensive and success- 
iiil He was one ol the first members of the royal society in London, whither he removed in 
i made his name as illustrious bv his writings, as lie had already done by his prac- 
tice. His works had been ofien printed separately ; but they were not collected till after hi* 
appened on the 11th of November, 1675. One edition was published at Geneva 
iu 1676, and another at Amsterdam in 1682, both in quarto. 

c 



xiv PREFACE. 

bimself has not applied his fundamental doctrine so extensively & 
he might have done ; and he has every where intermixed a Hu- 
moral Pathology, as incorrect and hypothetical as any other. 
Though he differed from his colleague Dr. Stahl in the fundamen- 
tal doctrines of his system, it is but too evident that he was very 
much infected with the Stahlion doctrines of Plethora and Ca- 
cochymy, as may be observed throughout the whole course of 
his work ; and particularly in his chapter De morborum generatione 
ex n'im'ia sanguinis quantitate et humorum impur'itate. 

But it is needless for me to dwell any longer upon the system 
of Hoffman ; and I am next to offer some remarks on the system 
of Dr. Boerhaave, the contemporary of both the other Systema- 
tics, and who, over all Europe, and especially in this part of the 
world, gained higher reputation than either of the others. 

Dr. Boerhaave* was a man of general erudition ; and, in ap- 
plying to medicine, he had carefully studied the auxiliary 
branches of Anatomy, Chemistry, and Botany, so that he excel- 
led in each. In forming a system of Physic, he seems to have 
studied diligently all the several writings of both ancient and mo- 
dern Physicians ; and, without prejudice in favor of any former 
systems, he endeavored to be a candid and genuine eeclectic. Pos- 
sessed of an excellent systematic genius, he gave a system su- 
perior to any that ever before appeared. As in the great extent, 
and seemingly perfect consistency, of system, he appeared to im- 
prove and refine upon every thing that had before been offered ;. 
and as in his Lectures he explained his doctrines with great 
clearness and elegance ; he soon acquired a very high reputation,, 
and his system was more generally received than any former had. 
been since the time of Galen. Whoever will consider die me- 

* Voorhoot, a small village about two miles from Leyden, gave birth lo this eminent physician 
on the last day of the year 1668. He was educated at Leyden, and took his first degree in phi- 
losophy 1690. His thesis on this occasion was a confutation of the doctrines of Epicurus,. 
Hobbes, and Spinosa : in which he shewed great strength of genius and argument. 
Although he was at this time well qualified to enter into the church, which was his fa- 
ther's intention, yet he was diffident of his abilities, and chose to attend the lectures of divinity 
longer. His patrimony was however now exhausted, and he supported himself at the university- 
by leaching mathematics, while he prosecuted his theological studies. This conduct was mueh 
approved by the eminent men both of the University and City, and procured for Boerhaave the 
friendship of Mr. Vanderburg the Burgomaster of Leyden. Under the patronage, and at the 
persuasion of this gentleman, Boerhaave applied himself to the study of physic with great ardor 
and indefatigable diligence. In a short time ne became proficient in anatomy, chemistry, and the 
materia medica, which indeed are the basis of physic. Leaving Leyden he' went to the univer- 
sity of Harderwick in Guelderland, and there look his degree of Doctor of Physic in July 1693. 
On his return to Leyden he still persisted in his intention of entering into the 'ministry, winch 
luckily, for the sake of Physic, was frustrated by the following adventure: In a passage boat 
where' Boerhaave was, a discourse was accidentally started about the doctrines of Spinosa as sub- 
versive of religion ; and one of the passengers, with vague invectives of blind zeal, o-.Tposed, 
this philosopher's pretended- mathematical demonstration. Boerhaave calmly asked him if he 
had read Spinosa 's work, which he had so much derided. The bigot, was suddenly struck dumb 
and became tired with silent resentment. As soon as he arrived at Leyden, he spread abroad a 
ru nor that Boerhaave was become a Spinosist. Boerhaave finding these prejudices to gain 
ground, thought it more prudent to pursue the science of physic, than risk the refusal of a li 
cence for the pulpit. He now joined the practice of Physic to the theory. On the ISth of 
Mav, 1701, he commenced his lectures on the Institutes of Physic. In 1709, he was created nro- 
fessorof medicine and botany; and in 1718, lie succeeded Le Mort in the professor>hii> of Che- 
mistry. In August 1722, he was seized wiih the ?out, and was obliged to resign his professorship 
of Chemistry and Botany in 17J9. He continued for some time to practice, but was at lenull" 
obliged to quit that also; and he died on the 23d of September 1738. ' 



PREFACE. -XV 

iits of Dr. Bocrhaave, and compare his system with that of for- 
mer writers, must acknowledge that he was very justly esteemed-, 
and gave a system which was at that time deservedly valued. 

But, in the progress of an inquisitive and industrious age, k 
was not to be expected that any system should last so long as 
Boerhaave's has done. The elaborate Commentary of Van Swie- 
ten on Boerhaave's system of practice, has been only finished a 
few years ago ; and though this Commentator has added many 
facts, and made some corrections, he has not, except in the parti- 
cular mentioned above, made any improvement in the general 
system. It is even surprising that Boerhaave himself, though he 
lived near forty years after he had first formed his system, had 
hardly in all that time made any corrections of it or additions to 
it ; the following is the most remarkable. In Aphorism 755, the 
words forte et nervosi, tarn cerebri quam cerchelli cordi destinati inertia, 
did not appear in any edition before the fourth ; and what a dif- 
ference of system this points at, every physician must perceive. 

When I first applied to the study of Physic, I learned only the 
system of Boerhaave ; and even when I came to take a Profes- 
sor's chair in this university, I found that system here in its 
full force; and as I believe it still subsists in credit elsewhere, and 
that no other system of reputation had been offered to the world, 
I think it necessary for me to point out particularly the imper- 
fections and deficiencies of the Boerhaavian system, in order to 
show the propriety and necessity of attempting a[new one. 

To execute this, however, so fully as I might, would lead me 
into a detail that can hardly be admitted of here ; and I hope it 
is not necessary, as I think, that every intelligent person , who has 
acquired any tolerable knowledge of the present state of our sci- 
ence, must in many instances, perceive its imperfections. I shall 
therefore touch only upon the great lines of this system ; and from 
the remarks I am to offer, trust that both the mistakes and defi- 
ciencies which run through the whole of his works will appear. 

Dr. Boerhaave's treatise of the diseases of the simple solid, 
has the appearance of being very clear and consistent, and was 
certainly considered by him as a fundamental doctrine ; but, in 
my apprehension, it is neither correct nor extensively applica- 
ble, not to mention the useless, and perhaps erroneous, notion of 
the composition of earth and gluten ; nor his mistake concerning 
the structure of compound membranes ; nor his inattention to the 
state of the cellular texture ; all of them circumstances which 
render his doctrine imperfect ; I shall insist only upon the whole 
being very little applicable to the explaining the phenomena of 
health or sickness. The laxity or rigidity of the simple solid, 
does, indeed, take place at the different periods of life, and may 
perhaps, upon other occasions, occur as the cause of disease : But 



xvi PREFACE. 

I presume, that the state of the simple solid is, upon few occa- 
sions, either changeable or actually changed ; and that, in ninety- 
nine cases of an hundred, the phenomena attributed to such a 
change, do truly depend on the state of the solidum viyum ; 
a circumstance which Dr. Boerhaave has hardly taken notice of 
in any part of his works. How much this shows the deficiency 
and imperfection of his system, I need not explain. The learned 
work of Dr. Gaubius, above referred to, as well as many other 
treatises of late authors, point out sufficiently the defects and im- 
perfections of Boerhaave on this subject. 

After Dr. Boerhaave has considered the diseases of the solids, 
he in the next place attempts to explain the more simple diseases 
of the fluids ; and there, indeed, he delivers a more correct doc- 
trine of acid and alkali than had been given before : But, after 
all, he has done it very imperfectly. We have, indeed, since his 
time, acquired more knowledge upon the subject of digestion ; 
and so much as to know, that a great deal more is yet necessary 
to enable us to understand in what manner the animal fluids are 
formed from the aliments taken in. And although Dr. Boer- 
haave has fallen into no considerable error with respect to a mor- 
bid aeidity in the stomach, he could not possibly be complete 
upon that subject ; and his notion of the effects of acidity in the 
mass of blood, seems to have been entirely mistaken, and is in- 
deed not consistent with what he himself has delivered elsewhere. 

His doctrine of alkali is somewhat better founded, but is pro- 
bably carried too far ; and the state of alkalescency and putrefac- 
tion, as well as all the other changes which can take place in the 
condition of animal fluids, are particulars yet involved in great 
obscurity, and are therefore still subjects of dispute. 

There is another particular, in which Boerhaave' s doctrine con- 
cerning the fluids appears to me imperfect and unsatisfactory ; and 
that is, in his doctrine de Glutinoso spontaneo. The causes which 
he has assigned for it are by no means probable, and the actual 
existence of it is seldom to be proved, Some of the proofs ad- 
duced for the existence of a phkgma calidum, are manifestly found- 
ed upon a mistake with respect to what has been called the in- 
flammatory crust, (See Van Sweiten's Commentary, page 96.) 
and the many examples given by Boerhaave of a glutlnosum ap- 
pearing in the human body, (Aph. 75.) are all of them nothing 
more than instances of collections or concretions found out of the 
course of die circulation. 

If, then, we consider the imperfections of Dr. Boerhaave's 
doctrine with respect to the state and various condition of the 
animal fluids ; and if at the same time we reflect how frequently 
he and his followers have employed the supposition of an acrimo- 
ny or lentor of the fluids, as causes of disease, and for directing 



PREFACE. xvii 

die practice ; we must, as I apprehend, be satisfied, that his sys- 
tem is not only deficient and incomplete, but fallacious and apt 
to mislead. Although it cannot be denied, that the fluids of the 
human body suffer various morbid changes ; and that upon these, 
diseases may primarily depend ; yet I must beg leave to maintain, 
that the nature of these changes is seldom understood, and more 
seldom still is it known when they have taken place : that out- 
reasonings concerning them have been, for the most part, purely 
hypothetical ; have therefore contributed nothing to improve, and 
have often misled, the practice of physic. In this, particularly, 
they have been hurtful, that they have withdrawn our attention^ 
from, and prevented our study of, the motions of the animal sys- 
tem, upon the state of which the phenomena of diseases do more 
certainly and generally depend. Whoever, then, shall consider the 
almost total neglect of the state of the moving powers of the 
animal body, and the prevalence of an hypothetical humoral pa- 
thology, so conspicuous in every part of the Boerhaavian system, 
must be convinced of its very great defects, and perceive the ne- 
cessity of attempting one more correct. 

After giving this general view, it is not requisite to enter into 
particulars; but, I believe, there are very few pages of his aphorisms 
in which there does not occur some error or defect ; although, 
perhaps, not to be imputed to the fault of Boerhaave, so much as 
to this, that since his time a great collection of new facts has 
been acquired by observation and experiment. This, indeed, af- 
fords the best and most solid reason for attempting a new system: 
for when many new facts have been acquired, it becomes requi- 
site that these should be incorporated into a system, whereby not 
only particular subjects may be improved, but the whole may be 
rendered more complete, consistent, and useful. Every system, 
indeed, must be valued in proportion to the number of facts that 
it embraces and comprehends ; and Mons. Quesney could not 
pay a higher compliment to the system of Boerhaave, than by 
saying that it exhibited La medicine collective. 

But here it will, perhaps be suggested to me, that the only use- 
ful work on the subject of physic, is the making a collection of 
all the facts that relate to the art, and therefore of all that expe- 
rience has taught us with respect to the cure of diseases. I agree 
entirely in the opinion ; but doubt if it can ever be properly ac- 
complished, without aiming at some system of principles, by a 
proper induction and generalisation of facts : at least I am per- 
suaded that it can be done not only very safely, but most usefully 
in this way. This, however, must be determined by a trial. I 
know that the late Mr. Lieutaud has attempted a work on the plan 
of collecting facts without any reasoning concerning their cau- 
ses : And while I am endeavoring to give some account of the 



xviii PREFACE. 

present state of physic, I cannot dismiss the subject without of- 
fering some remarks upon the promising Synopsis universa medici- 
na, composed by the first physician of a learned and ingenious 
nation. 

In this work there are many facts and much observation from 
the Author's own experience, which may be useful to those who 
have otherwise some knowledge and discernment ; but, through- 
out the whole work, there is such total want of method, arrange- 
ment, system, or decision, that in my humble opinion, it can be 
of little use, and may prove very perplexing to those who are yet 
to learn. The distinction of the genera of diseases, the distinc- 
tion of the species of each, and often even that of the varieties, I 
hold to be a necessary foundation of every plan of physic, whe- 
ther dogmatical or empirical. But very little of this distinction 
is to be found in the work of Mr. Lieutaud ; and in his preface he 
tells us, that he meant to neglect such arguta sedulitas. And indeed 
his method of managing his subject must certainly interrupt and 
retard all methodical nosology. His arrangement of diseases is 
according to no affinity, but that of the slightest and uninstruc- 
tive kind, the place of the body which they happen to affect. His 
Generalia et incerta sedis, have hardly any connection at all ; the ti- 
tles Rheumatisms, Hypocondriasis, Hydrops, follow one another. 
When he does attempt any general doctrine, it is not till long af- 
ter he has treated of die widely scattered particulars. Under 
each particular title which he assumes, he has endeavored to enu- 
merate the whole of the symptoms that ever appeared in a dis- 
ease under that title ; and this without aiming at any distinction 
between the essential and accidental symptoms, or marking the 
several combinations under which these symptoms do for the most 
part steadily appear. From the concurrence of accidental symp- 
toms, the variety of the same disease is frequently considerable, 
a circumstance necessarily perplexing and distracting to young 
practitioners ; but it seems strange to me, that an experience of 
thirty years, in considerable practice, could do nothing to relieve 
them. 

Mr. Lieutaud has at the same time increased the confusion 
that must arise from this want of distinction, by his considering 
as primary diseases, what appear to me to be the symptoms, ef- 
fects, and sequels, of other diseases only. Of this I think the 
JEstus morbosus, Virum exolutio, Dolores, Stagnatio sanguinis, Pu- 
rulentia, Tremor, Pervigilium, Raucedo, Suffocatio, Vomica, Em- 
pyema, Singultus, Vomitus, Dolor Stomachi, Tenesmus, all treated of 
under separate titles, are examples. A general symptomato- 
logia may be a very useful work, with a view to a System of 
Pathology ; but with a view to practice without any System, it 
must have bad effects as leading only to a palliative practice, 



PREFACE. xit 

xnd diverting from the proper efforts towards obtaining a radical 
cure. Mr. Lieutaud, indeed, has endeavored to exhibit the 
symptoms above mentioned as so many primary diseases : but he 
has seldom succeeded in this ; and, in delivering the practice he 
commonly finds it necessary to consider them as symptoms, and 
that not without some theory, implied or expressed, with re- 
spect to their proximate causes. His title of Do/ores may be tak- 
en as an example of this ; and from which it may be readily per- 
ceived how far such treatises can be really useful. 

In establishing a proper pathology, there i* nothing that has 
been of more service than the dissection of morbid bodies. Mr. 
Lieutaud has been much and most commendably employed in 
this way, and in this Synopsis he has endeavored to communicate 
his knowledge on the subject ; but in my humble opinion, he has 
seldom done it in a manner that can be useful. In the same way 
that he has delivered the symptoms of diseases without any in- 
structive arrangement ; so on the subject of the appearances af- 
ter death, he has mentioned every morbid appearance that had 
ever been observed after the disease of which he is then treating : 
but these appearances are strangely huddled together, without 
any notice taken of those which belong to one set of symptoms 
or to another ; and with regard to the whole, without any at- 
tempt to distinguish between the causes of diseases and the causes 
of death ; although the want of such distinction is the well known 
ground of fallacy upon this subject. I take for an example, the 
appearances mentioned as having been observed after dropsy. 
Here morbid appearances, found in every part of the body, in 
every cavity of it, and in every viscus contained in these cavities, 
are enumerated : but which of these morbid states are more fre- 
quent or more rare, and which has been more particularly con- 
nected with the different causes or with the different state of 
symptoms previously recited, we are not informed, nor has he 
enabled us to discover. In short, the dissection of morbid bo- 
dies has been, and may be, highly useful ; but in order to be so, it 
must be under a different management from what we find either 
in this Synopsis, or even in the Historia Anatomic o-medica. 

I cannot dismiss this subject without remarking, that the dis- 
section of morbid bodies, is chiefly valuable upon account of its 
leading us to discover the proximate causes of diseases ; and the 
great and valuable work of the illustrious Morgagni is properly 
intitled De sidebus et causis. It may well seem surprising, then, 
that Lieutaud should find the whole of proximate causes atra 
caligine tnersas ; and that he should never have thought of ap- 
plying his dissections towards the ascertaining at least some oi 
these. 

But let me now proceed to consider the important part of every 



xx PREFACE. 

practical work, and of this Synopsis universe median* : that is, 
the method of curing diseases. 

Here, again, upon the same plan as in giving the histories of 
disease, the method of cure is delivered by enumerating the 
whole of the remedies that have ever been employed in a disease 
under the title prefixed ; without assigning the species, or the 
circumstances to which the remedies, though of a very different 
and sometimes opposite nature, are particularly adapted. On 
the subject of Asthma, he very justly observes that physicians 
have been to blame in confounding, under this title, almost all 
the species of Dyspnoea ; and he himself very properly consi- 
ders Asthma as a disease distinct from all the other cases of 
Dyspnoea. Still, however, he considers Asthma as of many 
different species, arising from many different causes, which till 
we understand better, we cannot attempt to remove. Notwith- 
standing all this, he proceeds to deliver a very general cure. 
Parum abest, says he, quia specifici titulo gaudeant pectoralia, vulne- 
raria, et incidentia I But from such language I receive no clear 
idea ; nor can I obtain any clear direction from the enumeration 
of his medicines. Bacca juniperi, gummi, tragacanlhum vel ammo- 
niac um t sapo aqua picea, terebinthina, &c. qua tamen baud indiscrimi- 
natim sunt usurpanda, sed pro re nata, deluctu opus est. Very justly 
indeed, deluctu opus est ; but here, as in many other instances, 
he gives us no sort of assistance. 

From his endeavors, though not always successful, to neglect 
all system, his practice is generally delivered in a very indecisive 
manner ; or, what has the same effect, in a way so conditional 
as will render it always difficult, and often impossible, for a 
young practitioner to follow him. Let us take, for example, his 
cure of Dropsy. " The cure may be begun by blood-letting in 
certain conditions ; but in others, it cannot be employed 'without dan- 
ger. It gives relief in difficult breathing ; but, after it is practised, 
the symptoms are aggravated, and rendered more obstinate. It is not 
to be concealed that some persons have been cured by repeated 
blood-lettings, or spontaneous haemorrhagies ; but it is at the same 
time known, that such a remedy inopportunely employed, has in many 
instances hastened on the fatal event." 

In the same manner he treats of vomiting, purging, sweating, 
and the use of mineral waters ; but I must confess, that he has 
no where removed any of my doubts or difficulties, and indeed 
he has sometimes increased them. He says, that hepatics, or 
aperients, such as the lingua cervina, herbs capillares, &c. deserve 
commendation ; but that when the disease has arisen to a certain 
degree, they have been, for the most part, found to be useless. He 
observes, that the powder of toads given in wine, to the quan- 
tity of a scruple or more, has succeeded with severals. 



PREFACE. xxi 

Such are commonly, the methods of cure delivered by Mr. 
Lieutaud, longiori et forte feliciss'tma prax'i edoctus. 

It would be tedious to enter further into that detail, which a 
criticism of this immethodical and uninstructive work might lead 
me into ; but, if the bounds proper for this preface did not pre- 
vent me, I would particularly show that the work is far from be- 
ing free from those reasonings which the author pretends to 
avoid, and would affect even to despise. He still holds the doc- 
trines of the CONCOCTION and CRITICAL EVACUATION of MOR- 
BIFIC matter ; docrines depending upon subtile theories, and 
which, in my opinion, can in no wise be ascertained as matters 
of fact. Mr. Lieutaud likewise is still very much upon the old 
plan of following nature, and therefore gives often what I con- 
sider as a feeble and inert practice. The hamectantia, d'duentia, 
demulcentia, et temper antia, are with him very universal remedies, 
and often those which alone are to be employed. 

The mention of these medicines might lead me to take notice 
of Mr. Lieutaud's second volume, in which, ab insula remediorum 
farragine alienus, he promises a great reformation upon the sub- 
ject ; but this falls so far short of the idea of British physicians, 
that I need not make any remarks upon it. With respect to his 
list of simples, or Emporetica, as he is pleased to term them, an 
English apothecary would smile at it ; and with respect to his 
Officinalia, I believe they are to be found no where but in the 
Codex Mcdkamentartus of Paris ; and in his Mag'istralia his doses 
are generally such as the most timid practitioner of this country 
would hardly descend to ; and such as none of our practitioners 
of experience would depend upon. In short, the whole of the 
work, both with respect to the theories with which it abounds, 
and to the facts which it gives, will not, in my apprehension, 
bear any serious criticism. But I must conclude ; and shall only 
say further, that such as I have represented it, is this work, ex- 
ecuted by a man of the first rank in the profession. It is indeed 
for that reason I have chosen it as the example of a work, upon 
the plan of giving facts only, and of avoiding the study or even 
the notice of the proximate causes of diseases ; and with what 
advantage such a plan is pursued, I shall leave my readers to 
consider. 

In the following treatise I have followed a different course. I 
have endeavored to collect the facts relative to the diseases of the 
human body, as fully as the nature of the work and the bounds 
necessarily prescribed to it would admit : but I have not been sa- 
tisfied with giving the facts, without endeavoring to apply them 
to the investigation of proximate causes, and upon these to esta- 
blish a more scientific and decided measure of cure. In aiming 
at this, I flatter myself that I have avoided hypothesis, and what 

B 



Kxii PREFACE. 

have been called theories. I have, indeed, endeavored to esta- 
blish my general doctrines, both physiological and pathological ; 
but I trust that these are only a generalisation of facts, or con- 
clusions from a cautious and full induction ; and if any one shall 
refuse to admit, or directly shall oppose, my general doctrines, 
he must do it by showing that I have been deficient or mistaken 
in assuming and applying facts. I have, myself, been jealous of 
my being sometimes imperfect in these respects ; but I have ge- 
nerally endeavored to obviate the consequences of this, by prov- 
ing, that the proximate causes which I have assigned, are true in 
fact, as well as deductions from any reasoning that I may seem 
to have employed. Further, to obviate any dangerous fallacy in 
proposing a method of cure, I have always been anxious to sug- 
gest that which, to the best of my judgment, appeared to be the 
method approved of by experience, as much as it was the conse- 
quence of system. 

Upon this general plan I have endeavored to form a system of 
physic that should comprehend the whole of the facts relating to 
the science, and that will, I hope, collect and arrange them in 
better order than has been done before, as well as point out in 
particular those which are still wanting to establish general prin- 
ciples. This which I have attempted may, like other systems, 
hereafter suffer a change ; but I am confident that we are at pre- 
sent in a better train of investigation than physicians were in be- 
fore the time of Dr. Hoffman. The affections of the motions 
and moving powers of the animal economy, must certainly be 
the leading inquiry in considering the diseases of the human bo- 
dy. The inquiry may be difficult ; but it must be attempted, or 
the subject must be deserted altogether. I have therefore as- 
sumed the general principles of Hoffman, as laid down in the 
passage which I have quoted above ; and if I have rendered 
them more correct, and more extensive in their application ; and 
more particularly, if I have avoided introducing tire many 
hypothetical doctrines of the Humoral Pathology which disfi- 
gured both his and all the other systems which have hitherto pre- 
vailed ; I hope I shall be excused for attempting a system, which 
upon the whole may appear new. 



Edinburgh, Nov. 1789- 



FIRST LINES 

OF THE 

PRACTICE OF PHYSIC. 



INTRODUCTION 



1.] TN teaching the Practice of Physic, we endeavor 
A to give instruction tor discerning, distinguishing, 
preventing ', and curing diseases, as they occur in particular 
persons. 

2.] The art of discerning and distinguishing diseases, 
maj r be best attained by an accurate and complete observa- 
tion of their phenomena, as these occur in concourse and 
in succession, and by constantly endeavoring to distinguish 
the peculiar and inseparable concurrence of symptoms, to 
establish a Methodical Nosology, or an arrangement of 
diseases according to their genera and species, founded up- 
on observation alone, abstracted from all reasoning. Such 
an arrangement I have attempted in another work, to which 
in the course of the present 1 shall frequently refer. 

3.] The prevention of diseases depends upon the know- 
ledge of their remote causes j* which is partly delivered in 
the general Pathology, and partly to be delivered in this 
treatise. 

4.] The cure of diseases is chiefly, and almost unavoid- 
ably founded in the knowledge of their proximate causes, f 
This requires an acquaintance with the Institutions of Me- 
dicine ; that is, the knowledge of the structure, action, and 
Junctions of the human body ; of the several changes which 
it may undergo ; and of the several powers by whichitcan 

» Remote causes are of two kinds, viz. the predisposing and the exciting, or, as it is some- 
times called, the occasional. The predisposing is that which renders the body liable or capable 
of being affected !>v disease when the exciting cause is applied. No disease can exist without 
an occasional cause; vet it is necessary, that at the same tune, the State Of the body should be 
such as to admit that cause to take effect, or act. The predisposing cause is inherent in the body ; 
but it mav nevertlielcss be induced or changed by an external cause still more remote. Thus 
plethora may be the predisposing cause of many diseases, yet that same plethota may be induced 
by various causes previously acting on the body. The prevention of diseases is to avoid the ex- 
citing cause, and to correct that state ot the body, which renders it capable of being affected 0/ 
the exciting cause. ,. . hgt _ i , 

+ Proximate causes are those which immediately produce the disease, and \rlibse removn 
cures the disease. 



24 PRACTICE OF PHYSIC. 

be changed. Our knowledge of these particulars, however, 
is still incomplete, is in many respects doubttul, and has of- 
ten been involved in mistake and error. The doctrine, there- 
fore, of proximate causes, founded upon that knowledge, 
must be frequently precarious and uncertain. It is, how- 
ever, possible for a judicious physician to avoid what is vul- 
garly called theory, that is, all reasoning founded upon hy- 
pothesis, and thereby many of the errors which have for- 
merly taken place in the Institutions of Medicine. It is pos- 
sible also for a person who has an extensive knowledge of 
the facts relative to the animal occonomy in health and sick- 
ness, by a cautious and complete induction, to establish 
many general principles which may guide his reasoning with 
safety ; and while at the same time, a physician admits as 
a foundation of practice those reasonings only which are 
simple, obvious and certain, and for the most part admits 
as proximate causes those alone that are established as mat- 
ters of fact rather than as deductions of reasoning, he may 
with great advantage establish a system of practice chiefly 
founded on the doctrine of proximate causes. But when 
this cannot be done with sufficient certainty, the judicious 
and prudent physician will have recourse to experience 
alone ; always, however, aware of the hitherto incomplete 
and fallacious state of Empiricism. 

5.] With a strict attention to these considerations in the 
whole of the following Treatise, I proceed to treat of par- 
ticular diseases in the order of my Methodical Nosology. 



PART I. 

OF PYREXIAE, OR FERRILE DISEASES. 

6-3 T>YREXI;E, or febrile diseases, are distinguished 
JL by the following appearances. After beginning 
with some degree of cold shivering, they show some in- 
crease of heat, and an increased frequency of pulse, with 
the interruption and disorder of several functions, particu- 
larly some diminution of strength in the animal functions. 

7, I P f tnes . e p y rexi ^ I have formed a class, and have 
subdivided it into five orders of fevers, inflammations 
eruptions, hemorrhages, and fluxes.— Sec Synopsis 
Nosologic Methodicie, Edit. 3. 1780. 



25 

BO O K I. 

OF FEVERS. 

CHAPTER I. 
OF THE PHENOMENA OF FEVERS. 

8.] r T , HOSE diseases are more strictly called Fevers, 

X which have the general symptoms of Pyrexia, 

without having along with them any topical affection that 

is essential and primary, such as the other orders of the 

Pyrexiae always have. 

9.] Fevers, as differing in the number and variety of their 
symptoms, have been very properly considered as of dis- 
tinct genera and species. But we suppose that there are 
certain circumstances in common to all the diseases com- 
prehended under this order, which are therefore those essen- 
tially necessary to, and properly constituting the nature of 
fever. It is our business especially, and in the first place, 
to investigate these ; and I expect to find them as they oc- 
cur in the paroxysm, or fit, of an intermittent fever, as this 
is most commonly formed. 

10.] The phenomena to be observed in such a paroxysm 
are the following. The person is affected, first, with a lan- 
guor or sense of debility, a sluggishness in motion, and 
some uneasiness in exerting it, Avith frequent yawning and 
stretching. At the same time, the face and extremities be- 
come pale ; the features shrink ; the bulk of every exter- 
nal part is diminished ; and the skin over the whoie body, 
appears constricted, as if cold had been applied to it. At 
the coming on of these symptoms, some coldness of the ex- 
tremities, though little taken notice of by the patient, may 
be perceived by another person. At length, the patient 
himself feels a sensation of cold, commonly first in his back, 
but, from thence, passing over the whole body ; and now 
his skin feels warm to another person. The patient's sense 
•of cold increasing, produces a tremor in all his limbs, with 
frequent successions or rigors of the trunk of the body. 
When this sense of cold, and its effects, have cootinued tor 
some time, they become less violent, and are alternated with 



26 PRACTICE OF PHYSIC. 

warm flushings. By degrees, the cold goes off entirely ; 
and a heat, greater than natural prevails, and continues over 
the whole body. With this heat, the color of the skin re- 
turns, and a preternatural redness appears, especially in the 
face. Whilst the heat and redness comes on, the skin is re- 
laxed and smoothed, but for some time continues dry. The 
features of the face, and other parts of the body, recover 
their usual size, and become even more turgid. When the 
heat, redness, and turgescence have increased and continu- 
ed for some Lime, a moisture appears upon the forehead, 
and by degrees becomes a sweat, which gradually extends 
downwards over the whole body. As this sweat continues 
to Bow, the heat of the body abates ; the sweat, after con- 
tinuing some time, gradually ceases ; the body returns to 
its usual temperature ; and most of the functions are re- 
stored to their ordinary state.* 

11.] This series of appearances gives occasion to divide 
the paroxysm into three different stages ; which are called 
the cold, the hot, and the sweating stages or Fits. 

In the course of these, considerable changes happen in 
the state of several other functions, which are now to be 
mentioned. 

12.] Upon the first approach of languor, the pulse be- 
comes sometimes slower, and always weaker than before. 
As the sense of cold comes on, the pulse becomes smaller, 
very frequent, and often irregular. As the cold abates and 
the heat comes on, the pulse becomes more regular, hard 
and full ; and in these respects, increases till the sweat 
breaks out. As the sweat flows, the pulse becomes softer, 
and less frequent, till the sweat ceasing altogether, it re- 
turns to its usual state. 

13.] The respiration also suffers some changes. During 
the cold stage, the respiration is small, frequent and anxious, 
and is sometimes attended with a cough : as the hot stage 
comes on, the respiration becomes fuller and more free ; 
but continues still frequent and anxious, till the flowing of 
the sweat relieves the anxiety, and renders the breathing less 
frequent and more free. With the ceasing of the sweat, 
the breathing returns to its ordinary state. 

14.] The natural functions also suffer a change. Upon 
the approach of the cold stage, the appetite for food ceases, 
and does not return till the paroxysm be over, or the sweat 

* This description of a paroxysm is truly admirable. The symptoms are most accurately dt- 
rcribed, and the order ot their succession most strictly attended to by the author. 



PRACTICE OF PHYSIC. 27 

has flowed for some time. Generally during the whole of 
the paroxysm, there is not only a want of appetite, but an 
aversion from all solid, and especially animal food. As the 
cold stage advances, there frequently comes on a sickness 
and nausea, which often increase to a vomiting of a matter 
that is for the most part bilious. This vomiting commonly 
puts an end to the cold stage, and brings on the hot. As 
the hot stage advances, the nausea and vomiting abate ; and 
when the sweat breaks out, they generally cease altogether. 

15.] A considerable degree of thirst is commonly felt 
during the whole course of the paroxysm. During the cold 
stage, the thirst seems to arise from the dryness and clam- 
miness of the mouth and fauces, but during the hot stage, 
from the heat which then prevails over the whole body ; and 
as the sweat flows, the mouth becomes moister, and the 
thirst, together with the heat gradually abates.* 

16.] In the course of a paroxysm, there is often a con- 
siderable change in the state of the secretions. The cir- 
cumstances just now mentioned, show it in the secretion of 
the saliva and mucus of the mouth ; and it is still more re- 
markable with respect to the urine. During the cold stage, 
the urine is almost colorless, and without cloud or sediment. 
In the hot stage it becomes high colored, but is still with- 
out sediment. After the sweat has flowed freely, the urine 
deposits a sediment, commonly lateritious, and continues 
to do so for some time after the paroxysm is over. 

17.] Excepting in certain uncommon cases which are at- 
tended throughout with a diarrhoea, stools seldom occur till 
towards the end of a paroxysm, when commonly a stool 
happens, which is generally of a loose kind.f 

18.] Analogous to these changes in the state of the secre- 
tions, it frequently happens, that tumors subsisting on the 
surface of the body, suffer during the cold stage of fevers, 
a sudden and considerable detumescence ; but generally, 
though not always, the tumors return to their former size 
during the sweating stage. In like manner, ulcers are some- 

* The thirst in the cold and hot stages of the paroxysm seems to be a provident design of 
nature, and has been held forth as an argument for the existence of the vis mediratrix naturae. 
The paroxysm concludes with a profuse sweat; the production of this sweat requires an addi- 
tion.!! i|uantily of lluidity ; and nature, by means of the thirst, seems anxious to supply the quan- 
tity of fluid matter necessary for the perspiration that is requisite to remove the disease. 

+ The author's expression is here somewhat aukward : the meaning of the passage is, that 
itools seldom occur in the two first stages of a paroxysm, except in peculiar cases attended with 
dijrrhcra ; and if a stool happens about the end of the paroxysm, it is generally of a loose kind. 

A spontaneous diarrhoea always increases the violence of the symptoms, and the obstinacy of 
the disease. Hence the absurd practice of prescribing purges in agues, which never fail to exa- 
cerbate the paroxysms, and prolong their continuance. If any uneasiness arises from accumula- 
ted faxes in tire colon or rectum, they may be removed by emollient clysters. 



28 PRACTICE OF PHYSIC. 

times dried up during the cold stage ; and return again to 
discharge matter during the sweating stage, or after the 
paroxysm is over. 

19.] Certain changes appear also in sensation and thought. 
During the cold stage, the sensibility is often greatly im- 
paired ; but when the hot stage is formed, the sensibility 
is recovered, and often considerably increased. 

20.] With respect to the intellectual functions, when the 
cold stage comes on, attention and recollection become dif- 
ficult, and continue more or less so during the whole pa- 
roxysm. Hence some confusion of thought takes place, 
and often arises to a delirium, which sometimes comes on 
at the beginning of the cold stage, but more frequently not 
till the hot stage be formed. 

21.] It belongs also to this place to remark, that the cold 
stage sometimes comes on with a drowsiness and stupor, 
which often increase to a degree that may be called coma- 
tose, or apoplectic. 

22.] We have still to add, that sometimes, early in the 
cold stage, a headach comes on ; but which, more com- 
monly, is not felt till the hot stage be formed, and then is- 
usually attended with a throbbing of the temples. The 
headach continues till the sweat breaks out ; but as this 
flows more freely, that gradually goes off. At the same 
time with the headach, there are commonly pains of the 
back, and of some of the great joints ; and these pains have 
the same course with the headach. 

23.] These are nearly the whole, and are at least the chief 
of the phenomena which more constantly appear in the pa- 
roxysm of an intermittent fever ; and we have pointed out 
their ordinary concourse and succession. With respect to 
the whole of them, however, it is to be observed, that irr 
different cases, the several phenomena are in different de- 
grees ; that the series of them is more or less complete ; and 
that the several parts or stages in the time they occupy, are 
in a different proportion to one another. 

24.] It is very seldom that a fever consists of a single pa- 
roxysm, such as we have now described ; and it more gene- 
rally happens, after a certain length of time has elapscoMrom. 
the ceasing of the paroxysm, that the same series of pheno- 
mena again arises, and observes the same course as before ; 
and these states of fever and apirexia often continue to 
alternate with one another for many times. In such cases, 
the length of time from the end of one paroxysm to the be- 



PRACTICE OF PHYSIC. 29 

?; inning of another, is called an intermission ; and the 
ength of time from the beginning of one paroxysm to the be- 
ginning of another next succeeding, is called an interval. 

25.] When the disease consists of a number of paroxysms, 
it is generally to be observed, that the intervals between 
them are nearly equal ; but these intervals are of different 
lengths in different cases. The most usual interval is that 
of forty-eight hours, which is named the tertian period. 
The next most common is that of seventy-two hours, and 
is named the quartan period. Some other intervals are 
also observed, particularly one of twenty-four hours, nam- 
ed therefore, the quotidian ; and the appearance of this 
is pretty frequent. But all other intervals longer than that 
of the quartan are extremely rare, and probably are only 
irregularities of the tertian or quartan periods.* 

26.] The paroxysms of pure intermittent fevers are al- 
ways finished in less than. twenty-four hours: and though 
it happens that there are fevers which consist of repeated 
paroxysms, without any entire intermission betweem them ; 
yet in such cases it is observed, that though the hot and 
sweating stages of the paroxysm do not entirely cease be- 
fore the twenty-four hours from their beginning have ex- 
pired, they suffer, however, before that time, a considera- 
ble abatement or remission of their violence ; and at the 
return of the quotidian period, a paroxysm is in some 
shape renewed, which runs the same course as before. This 
constitutes what is called a remittent fever. 

27.] When in these remittents the remission is consider- 
able, and the return of a new paroxysm is distinctly mark- 
ed by the symptoms of a cold stage at the beginning of it; 
such fevers retain strictly the appellation of remittents. 
But when it happens, as it does in certain cases, that the 
remission is not considerable, is perhaps without sweat, 
and that the returning paroxysm is not marked by the most 
usual symptoms of a cold stage, but chiefly by the aggra- 
vation or exacerbation of a hot stage, the disease is cal- 
led a continued fever. 

28.] In some cases of continued fever, the remissions 
and exacerbations are so inconsiderable as not to be easily 

* Of ihe quotidian, tertian, and quartan intermittenls there are many varieties and forms; as 
the double tertian, having a paroxysm every day, wilh the alternate paroxysms similar to one 
another. The double tertian, with two paroxysms every other da}. The triple tertian, witU 
two paroxysms on one day, and another on the next. The double quartan, with two paroxysms 
on the first day, none on the second and third, and two again on the fourth day. The double 
quartan, with a paroxysm on the first day, another on the second, but none on the third. The 
triple quartan, with three paroxysms every fourth d3y. The triple quartan, with a paroxysm 
eT»ry day, every fourth paroxysm beinj similar. 



30 PRACTICE OF PHYSIC. 

observed or distinguished ; and this has led physicians to 
imagine, that there is a species of fever subsisting for se- 
veral davs together, and seemingly, consisting of one pa- 
roxysm only. This they haw called a continent fever ; 
but^ in a long course of practice, I have not had an op- 
portunity' of observing such a fever. 

'29.] It is, however, to be observed here, that the fevers 
of a continued form are to be distinguished i'roin one ano- 
ther ; and that, while some of a very continued form do 
still belong to the section of intennittents, there are others 
■which, though still consisting of separate and repeated pa- 
roxysms, yet as different from their causes and circumstan- 
ces from intennittents, are to be distinguished from the 
whole of these, and are more strictly to be called and con- 
sidered as continued.* Such are most of those which 
have been commonly supposed to be continent; and 
those which bv most writers have been simply named con- 
tinued ; and which term I have employed as the title of 
a section, to be distinguished from that of intermittent. 

I shall here add the marks by which, in practice, these 
different continued fevers may be distinguished from one 
another. 

Those fevers of a continued form, which, however, still 
belong to the section of Intermittent^; may be distinguish- 
ed by their having passed from an intermittent or remit- 
tent form, to that of a continued ; by their showing some 
tendency to become intermittent, or at least remittent ; by 
their being known to have been occasioned by marsh mias- 
mata ; and for the most part, by their having but one pa- 
roxysm, or exacerbation and remission, in the course of 
twenty-four hours. 

On the other hand, Continued Fevers, to be more strict- 
ly so called, may be distinguished by their showing little 
tendency to become intermittent or remittent in any part 
of their course, and especially after the first week of their 
continuance; by their being occasioned by human contagi- 
on, at least by other causes than the marsh miasmata ; and 
by their having pretty constantly an exacerbation and re- 
mission twice in the course of twenty-four hours. In both 
cases, the knowledge of the nature of the epidemic for the 
time prevailing, may have a great share in determining the 
nature of the particular fever. 

* This passage is very obscure : the author's meaning is, that some continued fevers nut on tlie 
appearance ofintermittents ; but beins different, in some peculiar and material circumstances, 
tfoax intennittents, are not to be classed with thtm. 



PRACTICE OF PHYSIC. 31 

30.] With respect to the form, or type of fevers, this 
further may be observed, That the quartan, while it has 
the longest interval, has at the same time, the longest and 
most violent cold stage ; but, upon the whole, the shortest 
paroxysm : That the tertian, having a shorter interval 
than the quartan, has at the same time, a shorter and less 
violent cold stage; but a longer paroxysm: And lastly, 
that the quotidian, with the shortest interval, has the least 
of a cold stage ; but the longest paroxysm. 

31.] The type of fevers is sometimes changed in their 
course. When this happens, it is generally in the follow- 
ing manner : Both tertians and quartans change into quo- 
tidians, quotidians into remittents, and these last become 
often of the most continued kind. In all these cases, the 
fever has its paroxysm protracted longer than usual, before 
it changes into a type of more frequent repetition. 

32.] From all this a presumption arises, that every fever 
consists of repeated paroxysms, differing from others chiefly 
in the circumstances and repetition of the paroxysms; and 
therefore, that it was allowable for us to take the paroxysm 
of a pure intermittent as an example and model of the 
whole. 



CHAPTER II. 

OF THE PROXIMATE CAUSE OF FEVER. 

33.] nr^HE proximate cause* of fever seems hitherto to 
X have eluded the research of physicians ; and 
1 shall not pretend to ascertain it in a manner that may 
remove every difficulty ; but I shall endeavor to make an 
approach towards it, and such as I hope, may be of use in 
conducting the practice in this disease : while at the same 
time 1 hope to avoid several errors which have formerly 
prevailed on this subject. 

34.] As the hot stage of fever is so constantly preceded 
by a cold stage, we presume that the latter is the cause of 
the former; and therefore that the cause of the cold stage 

* The author, in this chapter, delivers his favorite doctrine of universal spasm. It is by no 
means new, as he himself confesses in the preface, but borrowed trom Hoflman. The author, 
however, greatly improved the original idea, and brought the system to a greater degree of per- 
fection than it had been before. That there are weighty objections against it, cannot indeed be 
denied; it contains, however, much ingenuity ; and Dr. Cullen (by introducing it in this unj 
vrrtity) raised his name hifh in the annals oi medical fame. 



32 PRACTICE OF PHYSIC. 

is the cause of all that follows in the course of the parox- 
ysm. See Boerh. A ph. 1756. 

35.] To discover the cause of the cold stage of fevers, 
we may observe, that it is always preceded by strong marks 
of a general debility prevailing in the system. The small- 
ness and weakness of the pulse, the paleness and coldness 
of the extreme parts, with the shrinking of the whole bo- 
dy, sufficiently show that the action of the heart and larger 
arteries is, for the time, extremely weakened. Together 
with this, the languor, inactivity, and debility of the ani- 
mal motions, the imperfect sensations, the feeling of cold, 
while the bodv is truly warm, and some other symptoms, 
all shew that the energy of the brain is, on this occasion, 
greatly weakened ; and I presume, that as the weakness of 
the action of the heart can hardly be imputed to any other 
cause, this weakness also is a proof of the diminished ener- 
gy of the brain. 

36.] I shall hereafter endeavor to show, that the most 
noted of the remote causes of fever, as contagion, mias- 
mata, cold and fear, are of a sedative nature ; and there- 
fore render it probable that a debility is induced. Like- 
wise, when the paroxysms of a fever have ceased to be re- 
peated, they may again be renewed, and are most com- 
monly renewed by the application of debilitating powers. 
And further, the debility which subsists in the animal mo- 
tions and other functions through the whole of fever, ren- 
ders it pretty certain that sedative or debilitating powers* 
have been applied to the body. 

37.] It is therefore evident, that there are three states 
which always take place in fever : a state of debility, a 
state of cold, and a state of heat ; and as these three states 
regularly and constantly succeed each other in the order we 
have mentioned them, it is presumed that they are in the 
series of cause and effect with respect to one another. This 
we hold as matter of fact, even although, we should not 
be able to explain in what manner, or by what mechanical 
means these states severally produce each other. 

38.] How the state of debility produces some of the 
symptoms of the cold stage, may perhaps be readily ex- 
plained ; but how it produces all of them, I cannot ex- 
f)lain otherwise than by referring the matter to a general 
aw of the animal oeconomy, whereby it happens, that pow- 

* A purs;e administered six or seven days after tlie appearance of any paroxysm, has frequently 
occasioned a relapse, and is a practice that ought to be carefully avoided. I have generally 
found that purges given in the beginning of the disease, increase the difficulty of curing it. 



PRACTICE OF PHYSIC. 33 

ers which have a tendency to hurt and destroy the system, 
often excite such motions as are suited to obviate the ef- 
fects of the noxious power. This is the vis medicatjux 
xatur.e, so famous in the schools of physic ; and it seems 
probable, that many of the motions excited in fever are 
the effects of this power. 

39.] That the increased action of the heart and arteries, 
which takes place in the hot stage of fevers, is to be consi- 
dered as an effort of the vis medicatrix naturee, has been 
long a common opinion among physicians ; and I arn dis- 
posed to assert, that some part of the cold stage may be 
imputed to the same power. I judge so, because the cold 
stage appears to be universally a means of producing the 
hot ; because cold, externally applied, has very often si- 
milar effects ; and more certainly still, because it seems to 
be in proportion to the degree of tremor in the cold stage, 
that the hot stage proceeds more or less quickly to a ter- 
mination of the paroxsym, and to a more compleat solu- 
tion and longer intermission. See 30. 

40.] It is to be particularly observed, that during the cold 
stage of fever, there seems to be a spasm induced every 
where on the extremities of the arteries, and more especi- 
ally of those upon the surface of the body. This appears 
from the suppression of all excretions, and from the shrink- 
ing of the external parts; and although this may perhaps 
be imputed in part to the weaker action of the heart in 
propelling the blood into the extreme vessels; yet, as these 
symptoms often continue after the action of the heart is re- 
stored, there is reason to believe that a spasmodic constric- 
tion has taken place ; that it subsists for some time, and 
supports the hot stage ; for this stage ceases with the flowing 
of the sweat, and the return of other excretions, which are 
marks of the relaxation of vessels formerly constricted. 
Hoffman. Med. rat. System. Tom. 4. P. 1. Sect. 1. Cap. 
1. art. 4. 

4 1 .] The idea of fever, then, may be that a spasm of the 
extreme vessels, however induced, proves an irritation to 
the heart and arteries; and that this continues till the spasm 
is relaxed or overcome. There are many appearances 
which support this opinion ; and there is little doubt that 
a spasm does take place, which proves an irritation to the 
heart, and therefore may be considered as a principal part 
in the proximate cause of fever. It will still, however, re- 
main a question, what is the cause of this spasm; whether 



34 PRACTICE OF PHYSIC. 

it he directly produced by the remote cause of fever, or if 
it be onlv a part of the operation of the vis medicatrix nature. 

42.] I am disposed to be of the latter opinion, because in 
the first place, while it remains still certain that a debility- 
lays the foundation of fever, it is not obvious in what man- 
ner the debility produces the spasm, and what seems to be 
its effect, the increased action of the heart and arteries ; and 
secondly, because, in almost all the cases, in which an effort 
is made by the vis medicatrix nature, a cold fit and a spasm 
of the extreme vessels arc almost always the beginnings of 
such an effort. See G-iub. Pathol. Medici n. art. 750. 

43.] It is therefore presumed, that such a cold fit and 
spasm, at the beginning of fever, is a part of the operation 
of the vis medicatrix ; but, at, the same time, it seems to 
me probable, that during the whole course of the fever, 
there is an atony subsisting in the extreme vessels, and that 
the relaxation of the spasm requires the restoring of the 
tone and action of these. 

44.] This it may be difficult to explain; but I think it 
may be ascertained as a fact, by the consideration of the 
symptoms which ta]<e place, with respect to the functions of 
the stomach in fevers, such as the anorexia, nausea, and 
vomiting. (.14.) 

From many circumstances it is sufficiently certain, that 
there is a consent between the stomach and the surface of the 
body : and in all cases of the consent of distant parts, it is 
presumed to be by the connection of the nervous system, 
and that the consent which appears, is between the sentient 
and moving fibres of the one part with those of the other, is 
such, that a certain condition prevailing in the one part, oc- 
casions a similar condition in the other. 

In the case of the stomach and surface of the body, the 
consent particularly appears by the connexion which is ob- 
served between the state of the perspiration, and the state 
of the appetite in healthy persons ; and if it may be pre- 
sumed that the appetite depends upon the state of tone in 
the muscular fibres of the stomach, it will follow, that the 
connexion of appetite and perspiration depends upon a con- 
sent between the muscular fibres of the stomach, and the 
muscular fibres of the extreme vessels, or of the organ of 
perspiration, on the surface of the body. 

It is further in proof of the connexion between the appe- 
tite and perspiration, and at the same time of the circum- 
stances on which it depends, that cold applied to the surface 



PRACTICE OF PHYSIC. S5 

of the body, when it does not stop perspiration, but proves 
a stimulus to it, is always a powerful means of exciting ap- 
petite. 

Having thus established the connexion or consent mention- 
ed, we argue, that as the symptoms of anorexia, nausea, 
and vomiting, in many cases, manifestly depend upon a 
a state of debility or loss of tone in the muscular fibres of 
the stomach ; so it may be presumed, that these symptoms 
in the beginning of fever, depend upon an atony commu- 
nicated to the muscular fibres of the stomach, from the mus- 
cular fibres of the extreme vessels on the surface of the body. 

That the debility of the stomach which produces vomiting 
in the beginning of fevers, actually depends upon an atony of 
the extreme vessels on the surface of the body, appears par- 
ticularly from a fact observed by Dr. Sydenham. In the at- 
tack of the plague, a vomiting happens, which prevents any 
medicine from remaining on the stomach ; and Dr. Sy- 
denham tells us, that in such cases he could not overcome 
this vomiting but by external. means applied to produce a 
sweat; that is, to excite the action of the vessels on the 
surface of the body. 

The same connexion between the state of the stomach and 
that of the extreme vessels on the surface of the body, ap- 
pears from this also, that the vomiting, which so frequently 
happens in the cold stage of fevers, commonly ceases upon 
the coming on of the hot, and very certainly upon any 
sweat's coming out (14.) It is indeed probable, that the vo- 
miting in the cold stage of fevers, is one of the means em- 
ployed by nature for restoring the determination to the 
surface of the body ; and it is a circumstance affording 
proof, both of this, and of the general connexion between 
the stomach and surface of the body, that emetics thrown 
into the stomach, and operating there, in the time of the cold 
stage, commonly put an end to it, and bring on the hot stage. 

It also affords a proof of the same connexion, that cold 
water, taken into the stomach produces an increase of heat 
on the surface of the body, and is very often a convenient 
and effectual means of producing sweat. 

From the whole we have now said on this subject, I think it 
is sufficiently probable, that the symptoms of anorexia, nau- 
sea, and vomiting, depend upon, and are a proof of, an ato- 
ny subsisting in the extreme vessels on the surface of the 
body ; and that this atony therefore, now ascertained as a 



36 PRACTICE OF PHYSIC. 

matter of fact, may be considered as a principal circum- 
stance in the proximate cause of fever. 

45.] This atony* we supppose to depend upon a diminu- 
tion of the energy of the brain ; and that this diminution 
takes place in fevers, we conclude, not only from the debility 
prevailing in so many functions of the body, mentioned 
above (35.) but particularly from symptoms which are pe- 
culiar to the brain itself. Delirium is a frequent symptom 
of fever ; and as from the physiology and pathology we learn 
that this symptom commonly depends upon some inequality 
in the excitement of the brain or intellectual organ ; we hence 
conclude, that, in fever, it denotes some diminution in the en- 
ergy of the brain. Delirium, indeed, seems often to de- 
pend upon an increased impetus of the blood, in the vessels 
of the brain, and therefore attends phrenitis. It frequently 
appears also in the hot stage of fevers, accompanied with a 
headach and throbbing of the temples. But as the impetus 
of the blood in the vessels of the head is often considerably in- 
creased by exercise, external heat, passions, and other 
causes, without occasioning any delirium ; so, supposing 
that the same impetus, in the case of fever, produces deli- 
rium, the reason must be, that at the same time, there is 
some cause which diminishes the energy of the brain, and 
prevents a free communication between the parts concerned 
in the intellectual functions. Upon the same principles al- 
so, I suppose there is another species of delirium, depend- 
ing more entirely on the diminished energy of the brain, 
and which may therefore arise, when there is no unusual in- 
crease of the impetus of the blood in the vessels of the brain. 
Such seems to be the delirium occurring at the beginning of 
the cold stage of fevers, or in the hot stage of such fevers 
as show strong marks of debility in the whole system. 

46.] Upon the whole, our doctrine of fever is explicitly 
this. The remote causes (36.) are certain sedative powers 
applied to the nervous system, which diminishing the ener- 
gy of the brain, thereby produce a debility in the whole of 
the functions, (35.) and particularly in "the action of the 
extreme vessels, (43. 44.) Such, however, is, at the same 
time, the nature of the animal ceconomy, (38.) that this de- 
bility proves an indirect stimulus to the sanguiferous system ; 
whence, by the intervention of the cold stage, and spasm 
connected with it, (39. 40.) the action of the heart and 

(bTt i2l? rMd " Wi " pereeiYe ' thatthe whole of a* doctl ' in e deliyered in this chapter is hjrp„- 



PRACTICE OF PHYSIC. 37 

larger .arteries is increased, (40) and continues so (41.) till 
it has had the effect of restoring the energy of the brain, of 
extending this energy to the extreme vessels, of restoring 
therefore their action, and thereby especially overcoming 
the spasm affecting them ; upon the removing of which, 
the excretion of sweat, and other marks of the relaxation 
of excretories, take place. 

47.] This doctrine will, as I suppose, serve to explain 
not only the nature of fever in genera!, but also the various 
eases of it which occur. Before proceeding, however, to 
this, it may be proper to point out the opinions, and as 
I apprehend, the mistakes, which have formerly prevailed 
on this subject. 

48.] It has been supposed, that a lentor or viscidity pre- 
vailing in the mass of blood, and stagnating in the extreme 
vessels, is the cause of the cold stage of fevers and its con- 
sequences. But there is no evidence of any such viscidity 
previously subsisting in the fluids ; and as it is very impro- 
bable that such a state of them can be very quickly pro- 
duced, so the suddenness with which paroxysms come on, 
renders it more likely that the phenomena depend upon some 
cause acting upon the nervous system, or the primary mov- 
ing powers of the animal economy. See Van Svvieten apud 
Boerh. Aph. 775. 

49.] Another opinion, which has been almost universally 
received, is, that a noxious matter introduced into, or ge- 
nerated in, the body, is the. proximate cause of fever; and 
that the increased action of the heart and arteries, which 
forms so great a part of the disease, is an effort of the vis 
medicatrix naturte to expel this morbific matter ; and parti- 
cularly to change or concoct it, so as to render it either al- 
together innocent, or at least, fit for being more easily 
thrown out of the body. This doctrine, however, although 
of as great antiquity as any of the records of physic now 
remaining, and although it has been received by almost eve- 
ry school of medicine, yet appears to me to rest upon a very 
uncertain foundation. There are fevers produced by cold, 
fear, and other causes, accompanied with all the essential 
circumstances of fever, and terminating by sweat ; but, at 
the same time, without any evidence or suspicion of mor- 
bific matter. 

There have been fevers suddenly cured by a hemorrhagy, 
so moderate as could not carry out any considerable portion 
of a matter diffused over the whole mass of blood ; nor can 

F 



38 PRACTICE OF PHYSIC. 

we conceive how the morbific matter could be collected or 
determined to pass off by such an outlet as in that case is 
opened. 

Even supposing a morbific matter were present, there is 
no explanation given, in what manner the concoction of it' 
is performed ; nor is it shown that any such change docs in 
fact take place. In certain cases, it is indeed evident, that 
a noxious matter is introduced into the body, and proves 
the cause of fever ; but, even in these cases, it appears 
that the noxious matter is thrown out again, without having 
Suffered any change ; that the fever often terminates before 
the matter is expelled ; and that, upon many occasions, 
without waiting the supposed time of concoction, the fever 
can be cured, and that by remedies which do not seem to 
operate upon the fluids, or to produce any evacuation. 

50.] While we thus reason against the notion of fever be- 
ing an effort of nature, for concocting and expelling a mor- 
bific matter ; 1 by no means intend to deny that the cause 
of fever frequently operates upon the fluids, and particular- 
ly produces a putrescent state of them. I acknowledge that 
this is frequently the case ; but, at the same time, I main- 
tain, that such a change of the fluids is not commonly the 
cause of fever ; that very often it is an effect only ; and 
that there is no reason to believe the terminatiou of the fe- 
ver to depend upon the expulsion of the putrid matter. 

51.] Another opinion which has prevailed, remains still 
to be mentioned. In intermittent fevers, a great quantity of 
bile is commonly thrown out by vomiting ; and this is so 
frequently the case, that many have supposed an unusual 
quantity of bile, and perhaps a peculiar quality of it, to be 
the cause of intermittent fevers. This however, does not 
appear to be well founded. Vomiting, by whatever means 
excited, if too often repeated, with violent straining, seems 
to be powerful in emulging the biliary ducts, and common- 
ly throws out a great deal of bile. This will happen espe- 
cially in the case of intermittent fevers. For, as in the state 
of debility and cold stage of these fevers, the blood is not 
propelled in the usual quantity into the extreme vessels, and 
particularly into those on the surface of the body, but is ac- 
cumulated in the vessels of the internal parts, and particu- 
larly in the vena protarum ; so this may occasion a more 
copious secretion of bile. 

These considerations will, in some measure, account for 
the appearance of an unusual quantity of bile in intermittent 



PRACTICE OF PHYSIC. 39 

fevers; but the circumstance which chiefly occasions the 
appearance of bile in these cases, is the influence of warm 
climates and seasons. These seldom fail to produce a state 
of the human body, in which the bile is disposed to pass off, 
by its secretories, in greater quantity than usual ; and per- 
haps also'changed in its quality, as appears from the disease 
of cholera, which so frequently occurs in warm seasons. 
At the same time, this disease occurs often without fever ; 
and we shall hereafter render it sufficiently probable, that 
intermittent fevers, from the most part arise from another 
cause, that is, from marsh effluvia ; while on the other hand, 
there is no evidence of their arising from the state of the 
bile alone. The marsh effluvia however, commonly ope- 
rate most powerfully in .the same season that produces the 
change and redundance of the bile ; and therefore consi- 
dering the vomiting, and other circumstances of the inter- 
mittent fevers which here concur, it is not surprising that 
autumnal intermittents are so often attended with effusions 
of bile. 

This view of the subject does not lead us to consider the 
state of the bile as the cause of intermittents, but merely as 
a circumstance accidently concurring with them, from the 
state of the season in which they arise. What attention this 
requires in the conduct of the disease, I shall consider here- 
after. 

52.] From this view of the principal hypotheses which 
have hitherto been maintained with respect to the proximate 
cause of fever, it will appear, that fevers do not arise from 
changes in the state of the fluids ; hut that, on the contrary, 
almost the whole of the phenomena of fevers lead us to be- 
lieve, that they chiefly depend upon changes in the state of 
the moving powers of the animal system. Though we 
should not be able to explain all the circumstances of the 
disease, it is at least of some advantage to be led into the 
proper train of investigation. I have attempted to pursue 
it ; and shall now endeavor to apply the doctrine already de- 
livered, towards explaining the diversity of fevers. 



40 PRACTICE OF PHYSIC. 



CHAPTER III. 

OF THE DIFFERENCE OF FEVERS, AND ITS 
CAUSES. 

53.] HHO ascertain the difference of fevers, I think it 
A necessary to observe, in the first place, that eve- 
ry fever of more than one day's duration, consists of repeat- 
ed, and in some measure separate paroxysms ; and that the 
difference of fevers taken notice of above (from 25. to 30.) 
appears to consist in the different state of paroxysms, and in 
the different circumstances of their repetition. 

54.] That fevers generally consist of distinct, and in some 
measure separately repeated paroxysms, I have alledged 
above to be matter of fact ; but I shall here endeavor to con- 
firm it, by assigning the cause. 

55.] In every fever, in which we can distinctly observe 
any number of separate paroxysms, we constantly find that 
each paroxysm is finished in less than twenty-four hours ; 
but as I cannot perceive any thing in the cause of fevers de- 
termining to this, I must presume it to depend on some ge- 
neral law* of the animal economy. Such a law seems to be 
that which subjects the economy, in many respects to a di- 
urnal revolution. Whether this depends upon the original 
conformation of the body, or upon certain powers constant- 
ly applied to it, and inducing a habit, I cannot positively 
determine ; but the returns of sleep and watching, of appe- 
tites and excretions, and the changes which regularly occur 
in the state of the pulse, show sufficiently, that in the hu- 
man body a diurnal revolution takes place, 

56.] It is this diurnal revolution which, I suppose deter- 
mines the duration of the paroxysms of fevers ; and the 
constant and universal limitation of these paroxysms, (as ob- 
served in 55.) while no other cause of it can be assigned, 
renders it sufficiently probable, that their duration depends 
upon, and is determined by, the revolution mentioned. 
And that these paroxysms are connected with that diurnal 
revolution, appears further from this, that though the inter- 
vals of paroxysms are different in different cases, yet the 
times of the accession of paroxysms are generally fixed to 

* The reader will find entertainment in admiring the ingenuity of the author, in contrivin? 
several articles for maintaining his doctrine. One hypothesis piled on the top of another almost 
without end. 



PRACTICE OF PHYSIC. 41 

one time of the day ; so that Quotidians come on in the 
morning, Tertians at noon, and Quartans in the afternoon. 

57.] It remains to be remarked, that as Quartans and 
Tertians are apt to become Quotidians, these to pass into 
the state of Remittents, and these last to become Continued ; 
and that, even in the Continued form, daily exacerbations 
and remissions are generally to be observed ; so all this 
shows so much the power of diurnal revolution, that when 
in certain cases, the daily exacerbations and remissions are 
"with difficulty distinguished, we may still presume, that the 
general tendency of the economy prevails, that the dis- 
ease still consists of repeated paroxysms, and, upon the 
■whole, that there is no such disease as that which the schools 
have called a Continent Fever. I expect that this doctrine 
will be confirmed by what I shall say hereafter, concerning 
the periodical movements observed in continued fevers. 

58.] It being thus proved, that every fever, of more than 
one day's duration, consists of repeated paroxysms ; we, in 
the next place, remark, that the repetition of paroxysms 
depends upon the circumstances of the paroxysms which 
have already taken place. From what was observed (in 30. 
and 31.) it appears, that the longer paroxysms are protract- 
ed, they are the sooner repeated ; and therefore, that the 
cause of the frequent repetition is to be sought for in the cause 
of the protraction of paroxysms. 

59.] Agreeably to what is laid down in 46. andtotheopi- 
nion of most physicians, I suppose, that in every fever there 
is a power applied to the body, which has a tendency to 
hurt and destroy it, and produces in it certain motions which 
deviate from the natural state ; and at the same time, in eve- 
ry fever which has its full course, I suppose, that in conse- 
quence of the constitution of the animal economy, there are 
certain motions excited, which have a tendency to obviate 
the effects of the noxious power, or to correct and remove 
then). Both these kinds of motion are considered as con- 
stituting the disease. 

But the former is perhaps strictly the morbid state, while 
the latter is to be considered as the operation of the vis me- 
dicatrix natune of salutary tendency, and which I shall 
hereafter call the reaction of the system. 

60.] Upon the supposition that these two states take place 
in every paroxysm of fever, it will appear to be chiefly in the 
time of the hot stage that the reaction operates in removing 
the morbid state ; and therefore as this operation succeeds 



42 PRACTICE OF PHYSIC. 

more or less quickly, the hot stage of paroxysms will be 
shorter or longer. But as the length of paroxysms depends 
chiefly upon the duration of the hot stage, so the longer du- 
ration of this and of paroxysms, must be owing either to the 
obstinacy of resistance in the morbid state, or to the. weak- 
ness of the salutary reaction ; and it is probable that some- 
times the one, and sometimes the other of these circumstan- 
ces takes place. 

61.] It seems to be only by the state of the spasm, that 
we can judge of the resistance of the morbid state of fever; 
and with respect to this spasm 1 observe, that either the cause 
exciting it may be different in different cases ; or, though 
the cause should be the same in different persons, the differ- 
ent degree of irritability, in each may give occasion to a 
greater or lesser degree of spasm ; and therefore, the reac- 
tion in fever being given, the continuance of the hot stage, 
and of the whole paroxysm, may be longer or shorter, ac- 
cording to the degree of spasm that has been formed. 

62.] One cause of the obstinacy of spasm in fevers may 
be clearly perceived. In inflammatory diseases, there is a 
diathesis phlogistica prevailing in the body, and this diathe- 
sis we suppose to consist in an increased tone of the whole 
arterial system. When, therefore, this diathesis accompa- 
nies fever, as it sometimes does, it may be supposed to give 
occasion to the febrile spasm's being formed more strongly, 
and thereby to produce more protracted paroxysms. Ac- 
cordingly we find, thatall kiflammatory fevers are of the con- 
tinued kind ; and that all the causes of the diathesis phlogis- 
tica have a tendency to change intermittent into continued 
fevers. Continued fevers, then, being often attended with 
the diathesis phlogistica, we conclude, that, in many cases, 
this is the cause of their continued form. 

63.] In many fevers, however, there is no evidence of any 
diathesis phlogistica being present, nor of any other cause of 
more considerable spasm ; and, in such cases, therefore, we 
must impute the protraction of paroxysms, and the continu- 
ed form of the fever, to the weakness of reaction. That 
this cause takes place, Ave conclude from hence, that, in 
many cases of fever, wherein the separate paroxysms, are 
the longest protracted, and the most difficultly observed, Ave 
find the most considerable symptoms of a general debility : 
and therefore we infer, that in such cases, the protracted pa- 
roxysms, and continued form, depend upon a Aveaker reac- 
tion ; owing either to the causes of debility applied having 



PRACTICE OF PHYSIC. 43 

been of a more powerful kind, or from circumstances of the 
patient's constitution favoring their operation. 

64.] Upon these principles we make a step towards ex- 
plaining in general, with some probability, the difference of 
fevers ; but must own, that there is much doubt and difficul- 
ty in applying the doctrine to particular cases. It applies 
tolerably well to explain the different states of intermittents, 
as they are more purely such, or as they approach more 
and more to the continued form: but several difficulties 
still remain with respeet to many circumstances of intermit- 
tents; and more still with respect to the difference of those 
continued fevers, which we have distinguished in our Noso- 
logy as different from intermittents, and as more especially 
entitled to the appellation of Continued, (see Syn. Nos. 
Meth. P. V. Ch. I. Sect. II. ) and explained more fully 
above. 

65.] From the view given (63 and 64.) of the causes of 
the protraction of paroxysms, and therefore of the form of 
Continued Fevers, strictly so called, it seems probable, that 
the remote causes of these operate by occasioning either a 
phlogistic diathesis, or a weaker reaction ; for we can ob- 
serve, that the most obvious difference of continued fevers 
depends upon the prevalence of one or other of these 
states. 

66.] Continued fevers have been accounted of great di- 
versity ; but physicians have not been successful in marking 
these differences, or in reducing them to any general heads. 
The distinctions made by the ancients are not well under- 
stood; and, so far as either they or the modern nosologists 
have distinguished continued fevers by a difference of dura- 
tion, theirdistinctions are not well founded, and do not ap- 
ply in such a manner as to be of any use. We think it agree- 
able to observation, and to the principles above laid down, 
(63. 64.)to distinguish continued fevers according as they 
shew eitheran inflammatory irritation or a weaker reaction. 

67. ] This distinction is the same with that of fevers into 
the inflammatory and nervous ; the distinction at pre- 
sent most generally received in Britain. To the first as a 
genus, I have given the name of Synochus ; to the second, 
that of Typhus ; and little studious whether these names be 
authorised by the ancient use of the same terms, I depend, 
upon their being understood by the characters* annexed to 

* These characters are. Synocha. Calor pluriraum aurtus ; pulsus fre<iuens, validus, et du* 
nn i urina rubra ; sensorii ruuctionei plurimum turban? ; vires mulium iinainutx. 



44 PRACTICE OF PHYSIC. 

them in our Nosology, which I apprehend to be founded on 
observation. 

68.] By these characters I think continued fevers may in 
practice be distinguished ; and if that be the case, the prin- 
ciples above laid down will be confirmed. 

69.] Besides these differences of continued fever, now 
mentioned , I am not certain of having observed any other 
that can be considered as fundamental. But the most com- 
mon form of continued fevers, in this climate, seems to be 
a combination of these two genera ; and I have therefore 
given such a genus a place in our Nosology, under the ti- 
tle of Synochus. At the same time, I think that the limits 
between the Synochus and Typhus will be with difficulty 
assigned ; and I am disposed to believe, that the Synochus 
arises from the same causes as the Typhus, and is therefore 
onlv a variety of it. 

70.] The Typhus seems to be a genus comprehending 
several species. These, however, arc not yet well ascer- 
tained bv observation ; and in the mean time we can per- 
ceive that many of the different cases observed, do not im- 
ply any specific difference, but seem to be merely varieties 
arising from a different degree of power in the cause, from 
different circumstances of the climate or season in which 
they happen, or from different circumstances in the consti- 
tution of the persons affected. 

1 1 .] Some of the effects arising from these circumstances 
require to be particularly explained. 

One is, an unusual quantity of bile appearing in the 
course of the disease. This abundance of bile may possibly 
attend some continued fevers, strictly so called ; but, for 
the reasons above explained, it more commonly attends 
intermittents, and we believe, it might have been enume- 
rated (29.) among the marks distinguishing the latter kind 
of fevers from the former. But though an unusual quantity 
of bile should appear with continued fevers, it is consider- 
ed in this case, as in that of intermittents, to be a coinci- 
dence onlv, owing to the. state of the season, and produc- 
ing no different species or fundamental distinction, but 
merely a variety of the disease. I think it proper to ob- 
serve here, that it is probable that the most part of the con- 
tinued fevers named Bilious, have been truly such as belong 
to the section of Intermittents. 

72.] Another effect of the circumstances occasionally 
varying the appearance of typhus, is a putrescent state of 



PRACTICE OF PHYSIC. 45 

the fluids. The ancients, and likewise the moderns, who 
are in general much disposed to follow the former, have 
distinguished fevers, as putrid, and non putrid : but the 
notions of the ancients, on this subject, were not sufficient- 
ly correct to deserve much notice; and it is only of late 
that the matter has been more accurately observed, and 
better explained. 

From the dissolved state of the blood, as it presents itself 
when drawn out of the veins, or as it appears from the red 
blood's being disposed to be effused and run off by various 
outlets, and from several other symptoms to be hereafter 
mentioned, I have now no doubt, how much soever it has 
been disputed by some ingenious men, that a putrescency 
of the fluids, to a certain degree, does really take place in 
many cases of fever. This putrescency, however, often 
attends intermittent, as well as continued fevers, and of the 
continued kind, both the synochus and typhus, and all of 
them in very different degrees ; so that whatever attention 
it may deserve in practice, there is no fixing such limits to 
it as to admit of establishing a species under the title of 

PUTRID. 

73.] Beside differing by the circumstances already men- 
tioned, fevers differ also by their being accompanied with 
symptoms which belong to diseases of the other orders of 
pyrexia?. This sometimes happens in such a manner, as to 
render it difficult to determine which of the two is the pri- 
mary disease. Commonly, however, it may be ascertained 
by the knowledge of the remote cause, and the prevailing 
epidemic, or by observing the series and succession of 
symptoms. 

74.] Most of our systems of physic have marked, as a 
primary one, a species of fever under the title of hectic ; 
but as it is described, I have never seen it as a primary dis- 
ease. I have constantly found it as a symptom of some to- 
pical affection, most commonly of an internal suppuration; 
and as such it shall be considered in another place. 

75.] The distinction of the several cases of" intermittent 
fever I have not prosecuted here ; both because we cannot 
assign the causes of the differences which appear ; and be- 
cause I apprehend that the differences which in fact occur 
may be readily understood from what is said above (25. 26. 
and 27.) and more fully from our Methodical Nosology, 
Ch. I. Sect. I. 



M PRACTICE OF PHVSR' 

CHAFrER IV. 

OF THE REMOTE CAUSES OE FEFER. 

76.] A S fever has been held to consist chiefly in an in- 
jl\ creased action of the heart and arteries, phy- 
sicians have supposed its remote causes to be certain direct 
stimulants fitted to produce this increased action. In ma- 
ny cases, however, there is no evidence of such stimulants 
being applied ; and in those in which they are applied, they 
either produce only a temporary frequency of the pulse, 
which cannot be considered as a disease ; or, if they do 
produce a permanent febrile state, it is by the intervention 
of a topical inflammation, which produces a disease differ- 
ent from what is strictly called fever. (8.) 

77.] That direct stimulants arc the remote causes of fe- 
ver, seems farther improbable ; because the supposition 
does not account for the phenomena attending the acces- 
sion of fevers, and because other remote causes can with 
greater certainty be assigned. 

78.] As fevers are so generally epidemic, it is probable, 
that some matter floating in the atmosphere, and applied to 
the bodies of men, ought to be considered as the remote 
cause of fevers : And these matters present in the atmos- 
phere, and thus acting upon men, may be considered either 
as contagions, that is, effluvia arising directly or original- 
ly from the body of a man under a particular disease, and 
exciting the same kind of disease in the body of the per- 
son to whom they are applied ; or miasmata, that is, 
effluvia arising from other substances than the bodies of 
men, producing a disease in the person to whom they are 
applied. 

79.] Contagions have been supposed to be of great va- 
riety ; and it is possible this may be the case ; but that they 
truly are so, does not appear clearly from any thing we 
know at present. The genera and species of contagious 
diseases ; of the class of the Pyrexiae at present known, are in 
number not very great. They chiefly belong to the order of 
Fevers, to that of Exanthemata, or that of Profluvia. Whe- 
ther there be any belonging to the order of Phlegmasia?, is 
doubtful ; and though there should, it will not much in- 
crease the number of contagious pyrexias. Of the conta- 
gious exanthemata and profluvia, the number of species is 



PRACTICE OF PHYSIC. 41 

nearly ascertained ; and each of them is so far of a deter- 
mined nature, that though they have, now been observed 
and distinguished for many ages, and in many different parts 
of the world, they have been always found to retain the 
same general character, and to differ only in circumstances, 
that may be imputed to season, climate, and other exter- 
nal causes, or to the peculiar constitutions of the several 
persons affected. It seems, therefore probable, that in each 
of these species, the contagion is of one specific nature ; 
and that the number of contagious exanthemata or proiki- 
via is hardly greater than the number of species enumerat- 
ed in the systems of nosology. 

80.] If, while the contagious exanthemata and profluvia 
are thus limited, we should suppose the contagious pyrexia' 
to be still of great and unlimited variety, it must be with 
respect to the genera and species of continued fevers. But 
if I be right in limiting, as I have done, the genera of these 
fevers (67. — 70.) it will appear likely that the contagions 
which produce them are not of great variety : and this will 
be much confirmed, if we can render it probable that there 
is one principal, perhaps one common, source of such con- 
tagion. 

8 1 .] To this purpose it is now well known, that the efflu- 
via constantly arising from the living human body, if long 
retained in the same place, without being diffused in the at- 
mosphere, acquire a singular virulence ; and, in that state, 
being applied to the bodies of men, become the cause of a 
lever which is highly contagious. 

The existence of such a cause is fully proved by the late 
observations on jail and hospital fevers : and that the same 
virulent matter may be produced in many other places, must 
be sufficiently obvious : and it is probable that the conta- 
gion arising in this manner, is not, like many other conta- 
gions, permanent and constantly existing ; but that, in the 
circumstances mentioned, it is occasionly generated. At 
the same time, the nature of the fevers from thence, upon 
different occasions, arising, renders it probable that the vi- 
rulent state of human effluvia is the common cause of them, 
as they differ only in a state of their symptoms ; which may 
be imputed to the circumstances of season, climate, ike. 
concurring with the contagion, and modifying its force. 

82.] With respect to these contagions, though we have 
spoken of them as of a matter floating in the atmosphere, 
it is proper to observe, that they are never found to act 



48 PRACTICE OF PHYSIC. 

but when they arc near to the sources from whence they 
arise ; that is, either near to the bodies of men, from which 
they immediately issue; or near to some substances which, 
as having been near to the bodies of men, are imbued with 
their effluvia, and in which substances these effluvia are 
sometimes retained in an active state for a very long time. 

The substances thus imbued with an active and infec- 
tious matter, may be called, Fomites ; and it appears to 
me probable, that contagions, as they arise from fomites, 
are more powerful than as they arise immediately from the 
human body. 

83.] Miasmata are next to be considered. These may 
arise from various sources, and be of different kinds ; but 
we know little of their variety, or of their several effects. 
We know with certainty only one species of miasma, which 
can be considered as the cause of fever; and, from the uni- 
versality of this, it may be doubted if there be any other. 

84.] This miasma, so universally the cause of fever, is 
that which arises from marshes or moist ground, acted upon 
by heat. So many observations have now been made, with 
respect to this, in so many different regions of the earth, that 
there is neither any doubt of its being in general a cause 
of fevers, nor of its being very universally the cause of inter- 
mittent fevers, in all their different forms. The similarity 
of the climate, season, and soil, in the different countries 
in which intermittcnts arise, and the similarity of the dis- 
eases, though arising in different regions, concur in prov- 
ing, that there is one common cause of these diseases, and 
that this is the marsh miasma. 

What is the particular nature of this miasma, we know 
not ; nor do we certainly know whether or not it differs in 
kind ; but it is probable that it does not ; and that it varies 
only in the degree of its power, or perhaps as to its quan- 
tity, in a given space. 

85.] It has been now rendered probable, that the remote 
causes of fevers (8.) are chiefly Contagions or Miasmata, 
and neither of them of great variety. We have supposed 
that miasmata are the cause of intermittents, and contagions 
the cause of continued fevers, strictly so named ; but we 
cannot with propriety employ these general terms. For, 
as the cause of continued fevers may arise from fomites, and 
may, in such cases, be called a Miasma ; and as other mias- 
mata also may produce contagious diseases ; it will be pro- 
per to distinguish the causes of fevers, by using the terms 



PRACTICE OF PHYSIC. 49 

Human or Marsh Effluvia, rather than the general ones of 
< 'ontagion or Miasma. 

86.] To render our doetrine of fever consistent and com- 
plete, it is necessary to add here, that those remote causes 
of fever, human and marsh effluvia, seem to he of adebilitat- 
ing or sedative quality. They arise from a putrescent mat- 
ter. Their production is favored, and their power increas- 
ed, by circumstances which favor putrefaction ; and they 
often prove putrefactive ferments with respect to the animal 
fluids. As putrid matter, therefore, is always with respect 
to animal bodies, a powerful sedative, so it can hardly be 
doubted, that human and marsh effluvia are of the same 
quality : and it is continued by this, that the debility which 
is always induced, seems to be in proportion to the other 
marks that appear of the power of those causes. 

87.] Though we have endeavored to show that fevers 
generally arise from marsh or human effluvia, Ave cannot, 
with any certainty, exclude some other remote causes, 
which are commonly supposed to have at least a share m 
producing those diseases. And I proceed, therefore, to 
enquire concerning these causes ; the first of which that 
merits attention, is the power of cold applied to the human 
body. 

88.] The operation of cold on a living body, is so differ- 
ent in different circumstances, as to be of difficult explana- 
tion ; it is here, therefore, attempted with some diffidence. 

The power of cold may be considered as absolute or 
relative. 

The absolute power is that by which it can diminish the 
temperature of the body to which it is applied. And thus, 
if the natural temperature of the human body is, as we sup- 
pose it to be, that of 98 degrees of Farenheit's thermome- 
ter ;* every degree of temperature less than that, may be 
considered as cold with respect to the human body ; and, 
in proportion to its degree, will have a tendency to diminish 
tlie temperature of the body. But as the living human bo- 
(I v has in itself a power of generating heat, so it can sustain 
its own proper heat to the degree above mentioned, though 
surrounded by air or other bodies of a lower temperature 
than itself; and it appears from observation, that, in this 
climate, air, or other bodies applied to the living man, do 
not diminish the temperature of his body, unless the tem- 

* In every instance of our mentioning decrees of heat or cold, we shall mention them by the 
degrees in rarenheit's scale : and the expression of higher or lower shall always be according to 
Uul scale. 



50 PRACTICE OF PHYSIC. 

perature of the bodies applied be below 62 degrees. From 
hence it appears, that the absolute power of cold in this 
climate, does not act upon the living human body, unless 
the cold applied be below the degree just now mentioned. 

It appears also that the human body's being surrounded 
by air of a lower temperature than itself, is necessary to its 
being retained in its proper temperature of 98 degrees: for, 
in this climate, every temperature of the air above 62 de- 
grees, applied to the human body, though still of a lower 
temperature than itself, is found to increase the heat of it. 
And from all this it appears, that the absolute power of 
cold with respect to the human body, is very different from 
what it is with respect to inanimate bodies. 

89.] The illative power of cold with respect to the liv- 
ing human body, is that power by which it produces a sen- 
sation of eold in it ; and with respect to this, it is agreeable 
to the general principle of sensation, that the sensation pro- 
duced, is not in proportion to the absolute force of impres- 
sion, but according as the new impression is stronger or 
weaker than that which had been applied immediately be- 
fore. Accordingly, with respect to temperature, the sensa- 
tion produced by any degree of this, depends upon the 
temperature to which the body had been immediately be- 
fore exposed ; so that whatever is higher than this feels 
warm, and whatever is lower than it, feels cold ; and it will 
therefore happen that the opposite sensations of heat and 
cold may on different occasions arise from the same tem- 
perature, as marked by the thermometer. 

With respect to this, however, it is to be observed, that 
though every change of temperature gives a sensation of 
eold or heat as ^t is lower or higher than the temperature 
applied immediately before, the sensation produced is, in 
different cases, of different duration. If the temperature 
at any time applied is under 62 degrees, every increase of 
temperature applied will give a sensation of heat ; but if 
the increase of temperature does not arise to 62 deorees 
the sensation produced will not continue Jong, but be soon 
changed to a sensation of cold. In like manner, any tem- 
perature, applied to the human body, lower than that of 
the body itself, gives a sensation of cold ; but if the tem- 
perature applied does not go below 62 degrees, the sensa- 
tion of cold will not continue long, but be soon changed to 
a sensation of heat. 

It will appear hereafter, that the effects of the sensation 



PRACTICE OF PHYSIC. 51 

of cold will be very different, according as it is more per- 
manent or transitory. 

90.] Having thus explained the operation of cold, as ab- 
solute or relative, with respect to the human body, I pro- 
ceed to mention the general effects of cold upon it. 

1. Cold, in certain circumstances, has manifestly a seda- 
tive power. It can extinguish the vital principle entirely, 
either in particular parts, or in the whole body ; and con- 
sidering how much the vital principle of animals depends 
upon heat, it cannot be doubted that the power of cold is 
always more or less directly sedative. 

This effect may be said to take place from every degree 
of absolute cold ; and when the heat of the body has upon 
any occasion been preternaturally increased, every lower 
temperature may be useful in diminishing the activity of 
the system ; but it cannot diminish the natural vigor of the 
vital principle, till the cold applied is under 62 degrees ; 
nor even then will it have this effect, unless the cold applied 
be of an intense degree, or be applied for some length of 
time to a large portion of the body. 

2. It is equally manifest, that in certain circumstances, 
cold proves a stimulus to the living body, and particularly 
to the sanguiferous system. 

It is probable, that this effect takes place in every case, 
in which the temperature applied produces a sensation of 
cold ; and this, therefore, as depending entirely on the re- 
lative power of cold, will be in proportion to the change of 
temperature that takes place. 

It appears to me probable, that every change of tempe- 
rature, from a higher to a lower degree, will prove more 
or less stimulant ; excepting when the cold applied is so 
intense, as immediately to extinguish the vital principle in 
the part. 

3. Beside the sedative and stimulant powers of cold, it is 
manifestly also a powerful astringent, causing a contraction 
of the vessels on the surface of the body, and thereby pro- 
ducing a paleness of the skin, and a suppression of perspi- 
ration ; and it seems to have similar effects when applied 
to internal parts. It is likewise probable, that this con- 
striction, as it takes place especially in consequence of the 
sensibility of the parts to which the cold is applied, will in 
.some measure be communicated to other parts of the bo- 
dy ; and that thereby the application of cold proves a tonic 
power with respect to the whole system. 



52 PRACTICE OF PHYSIC. 

These effects of tonic and astringent power seem to take 
place both from the absolute and relative power of cold ; 
and therefore every application of it, which gives a sensa- 
tion of cold, is in its first effect, both astringent and stimu- 
lant, though the former may be often prevented from being 
either considerable or permanent, when the latter immedi- 
ately takes place. 

91.] It will be obvious, that these several effects of cold 
cannot all take place at the same time, but may in succes- 
sion be variously combined. The stimulant power taking 
place obviates the effeets, at least the permanency of the 
effeets, that might otherwise have arisen from the sedative 
power. That the same stimulant power prevents these 
from the astringent, I have said above ; but the stimulant 
and tonic powers of cold are commonly, perhaps always, 
conjoined. 

92.] These general effects of cold now pointed out are 
sometimes salutary, frequently morbid ; but it is the latter 
only I am to consider here, and they seem to be chiefly the 
following. 

1. A general inflammatory disposition of the system, 
which is commonly accompanied with Rheumatism, or 
other Phlegmasia-. 

2. The same inflammatory disposition accompanied with 
Catarrh. 

3. A Gangrene of particular parts. 

4. A Palsy of a single member. 

5. A Fever, or Fever strictly so called (8) which it of- 
ten produces by its own power alone, but more common- 
ly it is only an exciting cause of fever by concurring with 
the operation Of human or marsh effluvia. 

93.] Cold is often applied to the human body without 
producing any of these morbid effects, and it is difficult to 
determine in what circumstances it especially operates in 
producing them. It appears to me, that the morbid effects 
of cold depend partly upon certain circumstances of the 
cold itself, and partly on certain circumstances of the per- 
son to whom it is applied. 

94.] The circumstances of the cold applied, which seem 
to give it effect, are, 1 . The intensity or degree of the cold ; 
2. The length of time during which it is applied ; 3. The 
degree of moisture at the same time accompanying it ; 4. 
Its being applied by a wind or current of air ; 5. Its be- 



PRACTICE OF PHYSIC. 53 

ing a vicissitude, or sudden and considerable change of 
temperature, from heat to cold. 

95.] The circumstances of persons rendering them more 
liable to be affected by cold, seem to be, 1. The weakness 
of the system, and particularly the lessened vigor of the 
circulation, occasioned by fasting, by evacuations, by fa- 
tigue, by a last night's debauch, by excess in venery, by 
Jong watching, by much study, by rest immediately after 
great exercise, by sleep, and by preceding disease. 2. The 
body, or its parts, being deprived of their accustomed co- 
verings. 3. One part of the body being exposed to cold, 
while the rest is kept in its usual or a greater warmth. 

96.] The power of these circumstances (95) is demon- 
strated by the circumstances enabling persons to resist cold. 
These are a certain vigor of constitution, exercise of the 
body, the presence of active passions, and the use of cor- 
dials. 

Besides these, there are other circumstances which, by a 
different operation, enable persons to resist cold acting as a 
sensation ; such as, passions engaging a close attention to 
one object, the use of narcotics, and that state of the body 
in which sensibility is greatly diminished, as in maniacs. To 
all which is to be added, the power of habit with respect to 
those parts of the body to which cold is more constantly ap- 
plied, which both diminishes sensibility and increases the 
power of the activity generating heat. 

97.] Besides cold, there are other powers that seem to be 
remote causes of fever ; such as fear, intemperance in drink- 
ing, excess in venery, and other circumstances, which evi- 
dently weaken the system. But whether any of these seda- 
tive powers be alone the remote cause of fever, or if they 
only operate either as concurring with the operation of marsh 
or human effluvia, or as giving an opportunity to the opera- 
tion of cold, are questions not to be positively answered : 
they may possibly of themselves produce fever, but most 
frequently they operate as concurring in one or other of the 
ways above mentioned. 

98.] Having now mentioned the chief of the remote 
causes of fevers, it may be further observed, that these will 
arise more or less readily, according as miasmata and con- 
tagions are more or less prevailing and powerful, or as these 
are more or less favored by the concurrence of cold and other 
sedative powers. 

H 



54 PRACTICE OF PHYSIC. 

CHAPTER V. 

OF THE PROGNOSIS OF FEVERS. 

99.] A S fevers (by 60) consist of both morbid and salu- 
±\ tary motions and symptoms, the tendency of the 
disease to a happy or fatal issue, or the. prognostic in fevers, 
has been established by marking the prevalence of the morbid 
or of the salutary symptoms ; and it might be properly so 
established, if we could certainly distinguish between the 
one and the other of these kind of symptoms : but the ope- 
ration of the reaction, or salutaiy efforts of nature in curing 
fevers, is still involved in so much obscurity, that I cannot 
explain the several symptoms of it so clearly as to apply 
them to the establishing prognostics ; and this, I think, may- 
be done better, by marking the morbid symptoms which shew 
the tendency to death in fevers. 

100.] This plan of the prognostics in fevers must proceed 
upon our knowledge of the causes of death in general, and 
in fevers more particularly. 

The causes of death, in general, arc either direct or in- 
direct. 

The first are those which directly attack and destroy the 
vital principle, as lodged in the nervous system ; or destroy 
the organization of the brain immediately necessary to the 
action of that principle. 

The second, or the. indirect causes of death, are those 
which interrupt such functions as are necessary to the circu- 
lation of the blood, and thereby necessary to the due con- 
tinuance and support of the vital principle. 

101.] Of these general causes, those which operate more 
particularly in fevers seem to be, first, The violence of reac- 
tion ; which either by repeated violent excitements, destroys 
the vital power itself ; or, by its violence, destroys the or- 
ganization of the brain necessary to the action of that pow- 
er ; or, by the same violence, destroys the organization of 
the parts more immediately necessary to the circulation of 
the blood. 

Secondly, The cause of death in fevers may be a poison, 
that is, a power capable of destroying the vital principle ; 
and this poison may be either the miasma or contagion which 
was the remote cause of the fever, or it may be a putrid 
matter generated in the course of the fever. In both cases, 



PRACTICE OF PHYSIC. 55 

the operation of such a power appears either as acting chief- 
ly on the nervous system, inducing the symptoms of debility ; 
or as acting upon the fluids of the body, inducing a putre- 
scent state in them. 

102.] From all this it appears, that the symptoms show- 
ing the tendency to death in fevers, may be discovered by 
their being either the symptoms 
Of violent reaction ; 
Of great debility ; 

Or, of a strong tendency to putrefaction in the fluids. 
And upon this supposition, I proceed now to mark those 
symptoms more particularly. * 

103.] The symptoms which denote the violence of reac- 
tion, are I. The increased force, hardness, and frequency, 
of the pulse. 2. The increased heat of the body. 3. The 
symptoms which are the marks of a general inflammatory 
diathesis, and more especially of a particular determination 
to the brain, Jungs, or other important viscera. 4. The 
symptoms which are the marks of the cause of violent re- 
action ; that is of a strong stimulus applied, or of a strong 
spasm formed, the latter appearing in a considerable sup- 
pression of the excretions. 

104.] The symptoms which denote a great degree of de- 
bility, are, 

In the animal functions : I. The weakness of the vo- 
luntary motions ; II. The irregularis of the voluntary mo- 
tions, depending on their debility ; III. The weakness of 
sensation ; IV. The weakness and irregularity of the intel- 
lectual operations. 

In the vital functions : I. The weakness of the pulse; 
II. The coldness and shrinking of the extremities ; III. The 
tendency to a deliquium animi in an erect posture ; IV. The 
weakness of respiration. 

In the natural functions : I. The weakness of the 
stomach, as appearing in anorexia, nausea, and vomiting; 
II. Involuntary excretions, depending upon a palsy of the 
sphincters ; III. Difficult deglutition, depending upon a 
palsy of the muscles of the fauces. 

105.] Lastly, The symptoms denoting the putrescent state 
of the fluids, are, 

* No part of medical knowledge is so serviceable in the practice of physic as prognostics, rt 
wonderfully assists in the cure of all diseases, but more especially fevers, and other auute disor- 
x, therefore, ought to be particularly attentive to this part of the work. 
What the author advances is very different from what has gone before. We have here no hy- 
pothesis or lancies, iu> suppositions unsupported by facts ; but on the contrary' , truths deduced 
trum a careful observation of nature, and arranged in a distinct and perspicuous manner. 



56 PRACTICE OF HIYSIC. 

I. With respect to the stomach ; the loathing of animal 
food, nausea, and vomiting, great thirst, and a desire of acids. 

II. With respect to the fluids ; 1. The blood drawn out 
of the veins not coagulating as usual ; 2. Hemorrhagy from 
different parts, without marks of increased impetus ; 3. Ef- 
fusions under the skin or cuticle, forming patechia-, macu- 
lae, and vibices ; 4. Effusions of a yellow serum under the 
cuticle. 

III. With respect to the state of the excretions ; fetid 
breath, frequent loose and fetid stools, high colored turbid 
urine, fetid sweats, and the fetor and livid color of blistered 
places. 

IV. The candaverous smell of the whole body. 

106.] These several symptoms have very often, each of 
them singly, a share in determining the prognostic ; but 
more especially by their concurrence and combination with 
one another ; particularly those of debility with those of 
putrescency.* 

J 07.] On the subject of the prognostic, it is proper to ob- 
serve, that many physicians have been of opinion there is 
something in the nature of fevers which generally determines 
them to be of a certain duration ; and therefore that their ter- 
minations, whether sahitary or fatal, happen at certain pe- 
riods of the disease, rather than at others. These periods are 
called the critical days ; carefully marked by Hippocrates 
and other ancient physicians, as well as by moderns of the 
greatest eminence in practice ; whilst at the same time ma- 
ny other moderns, of no inconsiderable authority, deny their 
taking place in the fevers of these northern regions which 
we inhabit. 

108.] I am of opinion that the doctrine of the ancients, 
and particularly that of Hippocrates, on this subject, was 
well founded ; and that it is applicable to the fevers of our 
climate. 

109.] I am of this opinion, first, Because I observe that 
the animal economy, both from its own constitution, and 
from habits which are easily produced in it, is readily 
subjected to periodical movements. Secondly, Because, 
in the diseases of the. human body, I observe periodical 
movements to take place with great constancy and exact- 

* It may not be amiss to explain this circumstance a little more fullv. Coldness of the extre- 
mities mjy alone be sufficient to induce practitioners to think the issue of the disease fatal ■ ve' 
if this symptom be combined with a weakness and irregulariiv of the intellectual operations 
and these two accompanied with involuntary, loose, and foetid" evacuations of stool, and urine* 
PE.iTII may be pronounced to be at no great distance. 



PRACTICE OF PHYSIC. 57 

ness ; as in the case of intermittent fevers, and many other 
diseases. 

1 10i] These considerations render it probable, that exact 
periodical movements may take place in continued fevers ; 
and I think there is evidence of such movements actually 
taking place. 

111.] The critical days, or those on which we suppose the 
termination of continued fevers especially to happen, are, 
the third, fifth, seventh, ninth, eleventh, fourteenth, seven- 
teenth, and twentieth. We mark none beyond this last ; be- 
cause, though fevers are sometimes protracted beyond this 
period, it is, however, more rarely ; so that there are not a 
sufficient number of observations to ascertain the course of 
them ; and further, because it is probable that, in fevers long 
protracted, the movements become less exact and regular, 
and therefore less easily observed. 

1 12.] That the days now mentioned are the critical days, 
seems to be proved by the particular facts which are found 
in the writings of Hippocrates. From these facts, as collect- 
ed from the several writings of that author by M. de Haen, 
it appears, that of one hundred and sixty-three instances of 
the termination of fevers, which happened on one or other of 
the first twenty days of the disease, there are one hundred 
and seven, or more than two-thirds of the whole number, 
which happened on one or other of the eight days above 
mentioned ; that none happened on the second or thirteenth 
day ; and upon the eighth, tenth, twelfth, fifteenth, six- 
teenth, eighteenth, and nineteenth, there are but eighteen 
instances of termination, or one ninth of the whole. 

1 1 13.] As the terminations which happen on the seven davs 
last mentioned, are, upon the whole, few ; and, upon any 
one of them, fewer that those which happen on any of our 
supposed critical days; so there are therefore nine days which 
may be called noncritical ; while, on the other hand, the 
many terminations which happened on the seventh, four- 
teenth, and twentieth days, afford a proof both of critical 
days in general, and that these are the chief of them. Here- 
after I shall mention an analogy that renders the power of 
the other critical days sufficiently probable. 

114.] It appears further, that as, of the terminations 
which were final and salutary, not a tenth part happened on 
the noncritical days ; and of the terminations which were 
final and fatal, though the greater number happened on the 
(critical days, yet above a third of them happened on the non- 



58 PRACTICE OF PHYSIC. 

critical ; so it would appear that the tendency of the animal 
economy is to observe the critical days, and that it is by the 
operation of some violent and irregular cause that thetourse 
of things is sometimes turned to the noncritical. 

1 15. j What has been said gives sufficient ground for pre- 
suming, that it is the general tendency of the animal econo- 
my to determine the periodical movements in fevers to be 
chiefly on the critical days. At the same time, we must ac- 
knowledge it to be a general tendency only ; and that in par- 
ticular cases, many circumstances may occur to disturb the 
regular course of it. Thus, though the chief and more re- 
markable exacerbations in continued fevers happen on the 
critical days, there are truly exacerbations happening every 
day ; and these from certain causes, may become considera- 
ble and critical. Further, though intermittent fevers are 
certainly very strongly determined to observe a tertian or 
quartan period, we know there are certain circumstances 
"which prevent them from observing these periods exactly, 
and which render them either anticipating or postponing so 
much, that the days of paroxysms come to be quite changed ; 
and it is allowable to suppose, that the like may happen 
with respect to the exacerbations of continued fevers, so as 
thereby to disturb the regular appearance of critical days. 

A particular instance of this occurs with respect to the 
sixth day of fevers. In the writings of Hippocrates, there 
are many instances of terminations happening on the sixth 
day ; but it is not therefore reckoned among the critical 
days ; for of the terminations happening on that day, there 
is not one which proves finally of a salutary kind ; the 
greater number are fatal ; and all the rest are imperfect, 
and followed with a relapse. All this shews, that some vio- 
lent cause had, in these cases, produced a deviation from the 
ordinary course of nature ; that the terminations on the sixth 
day are nothing more than anticipations of the seventh, and 
therefore a proof of the power of this last.* 

116.] The doctrine of critical days has been much em- 
barrassed by some dissonant accounts of it, which appear in 
the writings imputed to Hippocrates, f But this may be 

* This idea of the general tendency of nature to preserve a regularity in the animal motions, 
is a most ingenious explanation of the apparent irregularities in the termination of fevers. It is 
perhaps one of the beji defences of the critical days that ever appeared, because it explains in 
;i most satisfactory manner, why the termination on the sixth day shou'd not be salutary. The 
violence of the disturbing cause'excites motions which nature has not the power of withstand- 
ing, and which are either the immediate causes of death or induce such morbid affections as 
prove ultimately fatal. 

+ To enter into a critical enquiry, whether the works handed down to us as the writings of 
Hippocrates are really the productions of that great man, or compilations from various physt- 



PRACTICE OF PHYSIC. 59 

justly accounted for from these writings being truly tlie 
works of different persons, and from the most genuine of 
them baring suffered many corruptions ; so that, in short, 
every thing which is inconsistent with the facts above laid 
down, may be ascribed to one or other of these causes. 

1 17.] This, further, has especially disturbed the doctrine 
of critical days, that Hippocrates himself attempted perhaps 
too hastily, to establish general rules, and to bring the doc- 
trine to a general theory, drawn from Pythagorean opinions 
concerning the power of numbers. It is this which seems 
to have produced the idea of odd clays, and of a quaternary 
and septenary period, doctrines which appear so often in the 
writings of Hippocrates. These, however, are inconsistent 
with the facts above laid down ; and indeed, as Asclepiades 
and Celsus have observed, are inconsistent with one another. 

118.] Upon the whole, therefore, it is apprehended, that 
the critical days above assigned are truly the critical days of 
Hippocrates, and may be consistently explained in the fol- 
lowing manner. 

1 19.] From the universality of tertian or quartan periods 
in intermittent fevers, we cannot doubt of there being, in 
the animal economy, a tendency to observe such periods ;* 
and the critical days above mentioned are consistent with 
this tendency of the economy, as all of them mark either 
tertian or quartan periods. These periods, however, are 
not promiscuously mixed, but occupy constantly their seve- 
ral portions in the progress of the disease ; so that, from the 
beginning to the eleventh day, a tertian period takes place, 
and, from the eleventh to the twentieth, and perhaps longer, 
a quartan period is as steadily observed. 

120.] What determines the periods to be changed about 
the eleventh day, we have not clearly perceived ; but the 
fact is certain : for there is no instance of any termination 
on the thirteenth, that is, the tertian period next following 
the eleventh ; whereas, upon the fourteenth, seventeenth, 
and twentieth, which mark quartan periods, there are forty- 
three instances of terminations, and six only on all the in- 
termediate days between these. 

cians, would be foreign to the design of this work. The style of them is, if I may be allowed the 
expression, homogeneous; the same provincial dialect prevails through the whole of them ; and 
they are extremely remarkable, especially sucli of them as respect the cruical days, for being ra- 
ther a detail of observed lacis, than reasonings brought to support a t.ivorile hypothc- 
probable indeed that Hippocrates, who has ?oi the credit of the work, might have been indebted 
toman] porahes for some of the materials that compose them ; but the sameness of 

the style is a strong presumptive argument that they are the pioducuonof one person, or at 
least of their having licen reduced to their present form by one and the same hand. Dr. Cullen's 
other supposition, of their having suffered many, and, he might have added, mateiial corruptions, 
;hly probable. 
♦ The Author might have added, or periods compounded of these uvo. 



60 PRACTICE OF PHYSIC. 

This prevalence of a quartan period leaves no room 1<-i 
doubting- that the twentieth, and not the twenty-first, is the 
critical day marked by Hippocrates, though the last is men- 
tioned as such in the common edition of the Aphorisms, 
taken from an erroneous manuscript, which Ceisus also 
seems to have copied. 

121.] A consistency with the general tendency of the sys- 
tem renders the series of critical days we have mentioned, 
probably the true one ; and the only remaining difficulty in 
finding what we have delivered to be the same with the 
genuine doctrine of Hippocrates, is the frequent mention 
of tlie fourth as a critical day. 

It is true there are more instances of terminations hap- 
pening on this day, than on some of those days we have as- 
serted to be truly critical : but its inconsistency with the 
more general tendency, and some other considerations, lead 
us to deny its being naturally a critical day ; and to think 
that the instances of terminations, which have really occur- 
red on the fourth day, are to be reckoned among the other 
irregularities that happen in this matter. 

122.] I have thus endeavored to support the doctrine of 
critical days, chiefly upon the particular facts to be found 
in the writings of Hippocrates: And although I might also 
produce many other testimonies of both ancient and modern 
times ; yet it must be owned, that some of these testimo- 
nies may be suspected to have arisen rather from a venera- 
tion of Hippocrates, than from accurate observation. 

123.] With respect to the opinions of many moderns 
who deny the prevalence of critical days, they are to be lit- 
tle regarded, for the observation of the course of continued 
fevers is known to be difficult and fallacious ; and therefore 
the regularity of that course may have often escaped inat- 
tentive and prejudiced observers. 

124.] Our own observations amount to this, That fevers 
with moderate symptoms, generally the cases of the syno- 
cha, frequently terminate in nine days, or sooner, and very 
constantly upon one or other of the critical davs which fall 
within that period : but it is very rare, in this climate, that 
cases of either the typhus or synochus terminate before the 
eleventh day ; and when they do terminate on this day, it 
is for the most part fatally. When they are protracted be- 
yond this time, I have very constantly found, that their ter- 
minations were upon the fourteenth, seventeenth, or twen- 
tieth day. 



PRACTICE OF PHYSIC. 6t 

In such cases, the salutary terminations are seldom attend- 
ed with any considerable evacuation. A sweating frequent- 
ly appears, but is seldom considerable ; and I have hardly 
ever observed critical and decisive terminations attended with 
vomiting, evacuations by stool, or remarkable changes in the 
urine. The solution of the disease is chiefly to be discerned 
from some return of sleep and appetite, the ceasing of deli- 
rium, and an abatement of the frequency of the pulse. By 
these symptoms we can often mark a crisis of the disease : 
but it seldom happens suddenly and entirely ; and it is most 
commonly from some favorable symptoms occurring upon 
one critical day, that Ave can announce a more entire solu- 
tion upon the next following. 

Upon the whole, I am persuaded, that if observations 
shall be made with attention, and without prejudice, I shall 
be allowed to conclude with the words of the learned and 
sagacious Gaubius, " Fallor, ni sua constiterit HippocRATr 
auctoritas, Galeno fides, naturae virtus et ordo." 



CHAPTER VI. 

OF THE METHOD OF CURE IN FEVERS, 

SECT. I. 

Of the Cure of Continued Fevers. 

12.5.] A S it is allowed, that in every fever which has 
ii its full course, there is an effort of nature of 
a salutary tendency, it might be supposed that the cure of 
fevers should be left to the operations of nature, or that 
our art should be only directed to support and regulate 
these operations, and that we should form the indications 
accordingly. This plan, however, I cannot adopt, because 
the operations of nature are very precarious, and not so well 
understood as to enable us to regulate them properly. It 
appears to me, that trusting. to these operations has often 
given occasion to a negligent and inert practice ; and there 
is reason to believe, that an attention to the operations of 
nature may be often superseded by art. 

126.] The plan which to me appears to be most suitabl« 
is that which forms the indications of cure upon the view 

I 



62 PRACTICE OF PHYSIC. 

of obviating the tendency to death ; while at the same time 
the means of executing these indications are directed by a 
proper attention to the proximate cause of fevers. 

Upon this plan, in consequence of what has been laid 
down above on the subject of the prognostic, we form three 
general indications in the cure of continued fevers; and the 
one or other of these is to be emploved according as the 
circumstances of the fever (102.) shall direct. 

The first therefore is-, To moderate the violence of reac- 
tion. 

The second is, To remove the causes or obviate the effects 
of debility. And, 

The third is, To obviate or correct the tendency of the 
fluids to putrefaction. 

127.] The first indication may be answered, that is, the 
violence of reaction may be moderated, 

1. By all those means which diminish the action of the 
heart and arteries. 

2. By those means which take off the spasm of the extreme 
vessels, which we suppose to be the chief cause of violent 
reaction. 

128.] The action of the heart and arteries may be di- 
minished, 

1. By avoiding or moderating those irritations, which in 
one degree or other, are almost constantly applied to the 
body. 

2. By the use of certain sedative powers. 

3. By diminishing the tension and tone of the arterial 
system. 

129.] The irritations (128. 1.) almost constantly applied, 
are the impressions made upon our senses ; the exercise of 
the body and mind; and the taking in of aliments. The 
avoiding these as much as possible, or the moderating their 
force, constitute what is rightly called the antiphlogistic 
regimen, proper to be employed in almost every continued 
fever. 

130.] The conduct of this regimen is to be directed by the 
following rules and considerations. 

1. Impressions on the external senses, as being stimulant 
to the system, and a chief support of its activity, should be 
avoided as much as possible ; those especially of more con- 
stant application, those of a stronger kind, and those which 
give pain and uneasiness. 

No impression is to be more carefully guarded against 



PRACTICE OF PHYSIC. €2 

than that of external heat ; while at the same time, every 
other means of increasing the heat of the body is to be shun- 
ned. Both these precautions are to be observed as soon as 
the hot stage is fully formed, and to be attended to during 
its continuance ; excepting in certain cases, where a deter- 
mination to sweating is necessary, or where the stimulant 
effects of heat may be compensated by circumstances which 
determine it to produce a relaxation and revulsion. 

2. All motion of the body is to be avoided, especially 
that which requires the exercise of its own muscles; and 
that posture of the body is to be chosen which employs the 
fewest muscles, and which keeps none of them long in a state 
of contraction. Speaking, as it accelerates respiration, is 
particularly to be refrained from. 

It is to be observed, that every motion of the body is the 
more stimulant, in proportion as the body is weaker. 

3. The exercise of the mind also is a stimulus to the bo- 
dy; so that all impressions, which lead to thought, and 
those especially which may excite emotion or passion, are 
to be carefully shunned. 

With respect to avoiding impressions of all kinds, an ex- 
ception is to be made in the case of a delirium coming on, 
when the presenting of accustomed objects may have the 
effect of interrupting and diverting the irregular train of 
ideas then arising in the mind. 

4. The presence of recent aliment in the stomach proves 
always a stimulus to the system, and ought therefore to be 
as moderate as possible. A total abstinence for some time 
may be of service ; but as this cannot be long continued 
with safety we must avoid the stimulus of aliment, by choos- 
ing that kind which gives the least.* We suppose that ali- 
mentary matters are more stimulant, according as they 
are more alkalescent; and this leads to avoid all animal, 
and to use vegetable food only. 

As our drinks also may prove stimulant, so all aromatic 
and spirituous liquors are to be avoided ; and in answering 
the present indication, all fermented liquors, excepting 
those of the lowest quality, are to be abstained from.f 

* In addition to these directions, it may be mentioned, that if the patient have a desire for 
food, which is seldom the case, he ought to make very sparing ana frequent meals. Much 
food taken at once, proves a greater stimulus than the same quantity taken at several different 
times ; especially if sufficient quantities of diluting mucilaginous drink, such as lintsced tea, 
barley-water, water-gruel, Sec. be taken along with it. 

+ Thin liquors are the best in casas of this kind : of these we may either use water alone, or 
weak lintsced tea, thin barley-water, toast and water, whey, currant-jelly dissolved in water, 
with a variety of suet kike mucilaginous acescent drinks. They ought te be uken in small qtian bi • 
ties, and often. 



64 PRACTICE OF PHYSIC. 

131.} Besides these stimulant powers more constantly ap- 
plied, there are others which, although occasionally only, 
yet, as commonly accompanying fevers, must be attended 
to and removed.* 

One is, the sense of thirst, which, as a powerful stimu- 
lus, ought always, in oneway or other to be removed, f 

Another stimulus frequently arises from crudities, or cor- 
rupted humors in the stomach ; and it is to be removed by 
-vomiting, by dilution, or by the use of acids. % 

A third stimulus often arises from the preternatural reten- 
tion of faeces in the intestines ; and ought to be removed by 
frequent]axativeglysters.|| 

A fourth stimulus to be constantly suspected in fevers, is 
a general acrimony of the fluids, as produced by the in- 
crease of motion and heat, joined with an interruption of 
the excretions. This acrimony is to be obviated or remo- 
ved by the taking in of large quantities of mild antiseptic 
liquors.^ 

132.] The avoiding of irritation in all these particulars, 
(130. and 131.) constitutes the antiphlogistic regimen ab- 
solutely necessary for moderating the violence of reaction; 
and, if I mistake not, is proper in almost every circum- 
stance of continued fevers; because the propriety and safe- 
ty of employing stimulants is often uncertain; and because 
several of those above mentioned, beside their stimulant 
powers, have other qualities by which they may be hurtful. 

It appears to me, that the supposed utility of stimulants, 
in certain cases of fever, has often arisen from a mistake in 
having ascribed to their stimulant, what really depended 
upon their antispasmodic power. 

133.] A second head of the means (128. 2.) for moderat- 
ing the violence of reaction, comprehends certain sedative 
powers, which may be employed to diminish the activity 
of the whole body, and particularly that of the sanguifer- 
ous system. 

* This passage might have been more clearly expressed thus: besides the stimulant power s 
more constantly applied, others, only occasionally accompanying fevers, must beattended to and 
removed. 

+ The drinks mentioned in the former note are best adapted to this purpose. 

i The vegetable acids are the most suitable, especially the juices of acid fruits, as the juices of 
oranges, lemons, currants or apples, diluted with water. In some cases the mineral acids have 
been much extolled, expecially the nitrous, when united with the spirit of wine. The spintus 
ajtheris nitrosi of the last London Pharmacopoeia is used with success in these cases. It may be 
given in barley water, to the quantity of twenty or twenty-five drops within the hour. 

II The preference of glysters to purging medicines is obvious. — The action even of the most 
.gentle laxatives is-always attended with some degree of stimulus, while glysters, especially the 
mild ones, seldom produce that effect. The best glyster in these cases, is half a point of milk, 
■with as much water, two ounces of oil, and one ounce of brown sugar, or, what is better than 
sugar, two ounces of manna. 

$ The chief of these are the acid fruits diluted with water: to which we may add the decoc- 
tion of malt, of radix graminis, (the Triticum repens of Linne,) infusions of sage, mint, and 
other plants of that natural order which Linne calls Spirantia. 



PRACTICE OF PHYSIC. €5 

'The first of these to be mentioned is the application of 
cold. 

Heat is the chief support of the activity of the animal 
system ; which is therefore provided in itself with a power 
of generating heat. But, at the same time we observe, 
that this would go to excess, were it not constantly moder- 
ated by a cooler temperature in thesurroundingatmosphere. 
When, therefore, that power of the system generating heat 
is increased, as is commonly the case in fevers, it is neces- 
sary not only to avoid all means of increasing it further, 
but it seems proper also to apply air of a cooler tempera- 
ture; or at least to apply it more entirely and freely, than 
in a state of health. 

Some late experiments in the small pox and in continued 
fevers, show that the free admission of cool air to the body, 
is a powerful remedy in moderating the violence of reaction ; 
but what is the mode of its operation, to what circumstances 
of fever it is peculiarly adapted, or what limitations it re- 
quires, I shall not venture to determine, till more particular- 
ly instructed by further experience. 

134.] A second sedative power which may be emploj'ed 
in fevers, is that of certam medicines, known, in the writ- 
ings on the Materia Medica, under the title of refrige- 
rants. 

The chief of these are acids of all kinds, when sufficient- 
ly diluted; and they are, in several respects, remedies adapt- 
ed to continued fevers. Those especially in use are, the 
Vitriolic and Vegetable; and, on many accounts, we pre- 
fer the latter.* 

135.] Another set of refrigerants are, the Neutral Salts, 
formed of the vitriolic, nitrous or vegetable acids; with al- 
kaline*, either fixed or volatile. All these neutrals, while 
they are dissolving in water, generate cold ; but as.that cold 
ceases soon after the solution is finished, and as the salts are 
generally exhibited in a dissolved state, their refrigerant 
power in the animal body does not at all depend upon 
their power of generating cold with water. The neutral 
chiefly employed as a refrigerant, is Nitre; but all the 

* The vitriolic acid is harsh to the taste, and frequently acts as an astringent : it is therefore 
not always admissible. The best vegetable acids for this purpose, arc as was saia above, the na- 
tural juices of acid fruits. The acid of tartar is the best refrigerant we have: there is an excel- 
lent formula of it in the Swedish Pharmacopoeia, under the title of Pulvis refrigerans, which con- 
sists chiefly of i he essential salt of tartar and sugar. The dose of the acid of tartar, prepared ac- 
cording to Schecle's prescription, is half a scruple, or fifteen grains, in the hour, largely diluted 
with a mucilaginous liquor. 



66 PRACTICE OF PHYSIC. 

others compounded as above mentioned, partake more or 
less of the same quality.* 

136.] Besides these neutrals, some metallic salts also 
have been employed as refrigerants in fevers; and particu- 
larly the Sugar of Lead. But the refrigerant powers of 
this are not well ascertained; and its deleterious qualities 
are too well known to admit of its being freely used. 

137.] Under the third general head (128. 3.) of the 
means to be employed for moderating the violence of reac- 
tion, are comprehended the several means of diminishing 
the tension, tone, and activity, of the sanguiferous system. 
As the activity of this system depends, in a great measure, 
upon the tone, and this again upon the tension of the ves- 
sels, given to them by the quantity of fluids they contain, 
it is evident, that the diminution of the quantity of these 
must diminish the activity of the sanguiferous system. 

138.] The quantity of fluids contained in the sanguifer- 
ous system, may be diminished most conveniently by the 
evacuations of blood-letting and purging. 

139.] Nothing is more evident, than that blood-letting 
is one of the most powerful means of diminishing the activ- 
ity of the whole body, especially rtf the sanguiferous system ; 
and it must therefore be the most effectual means of moder- 
ating the violence of reaction in fevers. Taking this as a 
fact, I omit inquiring into its mode of operation and shall 
only consider in what circumstances of fevers it may be 
most properly employed. 

140.] When the violence of reaction, and its constant 
attendant, a phlogistic diathesis, are sufficiently manifest ; 
when these constitute the principal part of the disease, and 
may be expected to continue throughout the whole of it as 
in the cases of synocha; then blood-letting is the principal 
remedy, and may be employed as far as the symptoms of 
the disease may seem to require, and the constitution of 
the patient will bear. It is, however, to be attended to, that 
a greater evacuation than is necessary, may occasion a 
slower recovery, may render the person more liable to a re- 
lapse, or may bring on other diseases. 

141.] In the case of synocha, therefore, there is little 
doubt about the propriety of blood-letting : but there are 
other species of fever, as the synochus, in which a violent 

* Nitre has been long used as a refrigerant. In too large quantities, however, it has often 
4one harm. It may there'ore be necessary to guard !he young practitioner against giving nitre 
in a larger quantity than two drachms in the tw«nty-fo»r hours, nor la doses ©f atteve ten grain*, 
wril diluted with mucilaginous drinks. 



PRACTICE OF PHYSIC. frl 

reaction and phlogistic diathesis appear, and prevail du- 
ring some part of the course of the disease ; while at the 
same time, these circumstances do not constitute the prin- 
cipal part of the disease, nor are to be expected to continue 
during the whole course of it, and it is well known, that in 
many cases, the state of violent reaction is to be succeeded, 
sooner or later, by a state of debility from the excess of 
which the danger of the disease is chiefly to arise. It is, 
therefore, necessary, that, in many cases, blood-letting 
should be avoided, and even although, during the inflam- 
matory state of the disease, it may be proper, it will be ne- 
cessary to take care that the evacuation be not so large as 
to increase the state of debility which is to follow. 

142.] From all this it must appear, that the employing 
blood-letting, in certain fevers, requires much discernment 
and skill, and is to be governed by the consideration of the 
following circumstances ; 

1. The nature of the prevailing epidemic. 

2. The nature of the remote cause. 

3. The season and climate in which the disease occurs. 

4. The degree of phlogistic diathesis present.* 

5. The period of the disease. 

6. The age, vigor, and plethoric state of the patient. 

7. The patient's former diseases and habits of blood-let- 
ting. 

8. The appearance of the blood drawn out. 

9. The effects of the blood-letting that may have bee* 
already practised. 

143.] When after the consideration of these circum- 
stances, blood-letting is determined to be necessary, it 
should be observed, that it is more effectual, according as 
the blood is more suddenly drawn off, and as the body is at 
the same time more free from all irritation, and consequently 
when in a posture in which the fewest muscles are in action. 

144.] Another evacuation whereby the quantity of fluids 
contained in the body can be considerably diminished, is 
that of purging. 

145.] II we consider the quantity of fluids constantly 
present in the cavity of the intestines, and the quantity 
which may be drawn from the innumerable excretories that 
open into this cavity, it will be obvious, that a very great 
evacuation can be made by purging; and, if this be done 
by a stimulus applied to the intestines, without being at the 

* The phlogistic diathesis is explained in art. 347. 



68 PRACTICE OF PHYSIC. 

same time communicated to the rest of the body, it may, 
by emptying both the cavity of the intestines, and the arte- 
ries which furnish the excretions poured into it, induce a 
considerable relaxation in the whole system ; and therefore, 
purging seems to be a remedy suited to moderate the vio- 
lence of reaction in fevers. 

146.] But it is to be observed, that as the fluid drawn from 
the excretories opening into the intestines, is not all drawn 
immediately from the arteries, as a part of it is drawn from 
the mucous follicles only ; and what is even more immedi- 
ately drawn from the arteries, is drawn off slowly, so the 
evacuation will not, in proportion to its quantity, occasion 
such a sudden depletion of the red vessels, as blood-letting 
docs ; and therefore cannot operate so powerfully in taking 
off the phlogistic diathesis of the system. 

147.] At the same time, as this evacuation may induce 
a considerable degree of debility ; so, in those cases, in 
which a dangerous state of debility is likely to occur, purg- 
ing is to be employed with a great deal of caution ; and more 
especially as the due measure of the evacuation is more 
difficult to be applied than in the case of blood-letting. 
148.] As we shall presently have occasion to observe, 
that it is of great importance, in the cure of fevers, to re- 
store the determination of the blood to the vessels on the 
surface of the body ; so purging, as in some measure tak- 
ing off that determination, seems to be an evacuation not 
well adapted to the cure of fevers. 

149.] If, notwithstanding these doubts, (146. 147. and 
148.) it shall be asserted, that purging, even from the ex- 
hibition of purgatives, has often been useful in fevers ; I 
would beg leave to maintain, that this has not happened 
from a large evacuation ; and therefore, not by moderating 
the violence of reaction, excepting in the case of a more 
purely inflammatory fever, or of exanthemata of an inflam- 
matory nature. In other cases of fever*, I have seen a large 
evacuation by purging, of mischievous consequence ; and if 
upon occasion, a more moderate evacuation has appeared 
to be useful, it is apprehended to have been only by taking 
off the irritation^of retained faeces, or by evacuating cor- 
rupted humors, which happened to be present in the intes- 
tines ; for both of which purposes, frequent laxatives may 
be properly employed.* 

" * Purges ought to be very cautiously administered in fevers ; and such only are to be used as 
operate with the least irritation. In fevers attended with local inflammation, we may be under -no 
apprehension of dangereven from the brisker puiges, as Glauber's salt, given in the quantity of 



PRACTICE OF PHYSIC. cd 

150.] Another set of means (127. 2.) for moderating the 
violence of reaction in ferers, are those suited to take off 
the spasm of the extreme vessels, which we believe to be 
the irritation that chiefly supports the reaction. 

Though I have put here this indication of taking off the 
spasm of the extreme vessels, as subordinate to the general 
indication of moderating the violence of reaction ; it is, 
however, to be observed here, that as fever universally 
consists in an increased action of the heart, either in fre- 
quency or in force, which in either case is supported by a 
spasm of the extreme vessels, so the indication for remov- 
ing this is a very general one, and applicable in almost eve- 
ry circumstance of fever, or at least, with a few exceptions, 
to be taken notice of hereafter. 

151.] For taking off the spasm of the extreme vessels, 
the means to be employed are either internal or external. 

152.] The internal means (151.) are, 

1 . Those which determine the force of the circulation to 
the extreme vessels on the surface of the body, and, by re- 
storing the tone and activity of these vessels, may overcome 
the spasm on their extremities. 

2. Those medicines which have the power of taking off 
spasm in any part of the system, and which are known un- 
der the title of ANTISPASMODICS. 

153.] Those remedies which are fit to determine to the 
surface of the body, are, • 

1. Diluents. 

2. Neutral Salts. 
s. sudorifics. 

4. Emetics. 

154.] Water enters, in a large proportion, into the com- 
position of all the animal fluids, and a large quantity of it 
is always diffused through the whole of the common mass. 
Indeed, in a sound state, the fluidity of the whole mass de- 
pends upon the quantity of water present in it. Water, 
therefore is the proper diluent of our mass of blood ; and 
other fluids are diluent only in proportion to the quantity 
of water they contain. 



an ounee,or an ounce and a half, or three or four ounces of the infusum sennte, with half an 
ounce of Glauber's salt and a drachm or two of tincture of jalap ; but in fevers where no topical 
HiHammation appears, the purees, if necessary, must be o! the mildest kind, such as manna, cas- 
si.i, Sec. and they must be given in small and often repeated dozes. Inmost fevers the intes- 
tines may be sufficiently evacuated by taking half an ounce of manna, and a scruple of cream of 
tartar, every hour till it operates, diluting plentifully at the same time with barley-water. The 
phosphorated soda, lately introduced into practice by the ingenious Dr. Pearson of London, is 
well calculated for these cases. The doac of it is an ounce or ten drachms in bailey -water or UrotW. 

K 



70 PRACTICE OF PHYSIC. 

155. Water may be said to be the vehicle of the several 
matters which ought to be excerned ; and in a healthy 
state the fulness of the extreme vessels, and the quantity of 
excretions, are nearly in proportion to the quantity of wa- 
ter present in the body. In lever, however, although the 
excretions are in some measure interrupted, they continue 
in such quantity as to exhale the more fluid parts of the 
blood ; and while a portion of them is at the same time ne- 
cessarily retained in the larger vessels, the smaller and the 
extreme vessels, both from the deficiency of fluid, and their 
own contracted state, are less filled, and therefore allowed 
to remain in that condition. 

156.] To remedy this contracted state, nothing is more 
necessary than a large supply of water or watery fluids, ta- 
ken in by drinking or otherwise ; for as any superfluous 
quantity of water is forced off by the several excretorics, 
such a force applied, may be a means of dilating the ex- 
treme vessels, and of overcoming the spasm affecting their 
extremities. 

157.] Accordingly the throwing in of a large quantity of 
watery fluids has been, at all times, a remedy much em- 
ployed in fevers ; and in no instance more remarkably, 
than by the Spanish and Italian physicians, in the use of 
what they call the Dioeta aquect. 

158.] This practice consists in taking away every other 
kind of aliment and drink, and i» giving in divided portions 
every day, for several days together, six or eight pounds 
of plain water, generally cold, but sometimes warm. All 
this, however, is to be done only after the disease has con- 
tinued for some time, and, at least, for a week.* 

159.] A second means (153. 2.) of determining to the 
surface of the body, is by the use of neutral salts. These, 
in a certain dose taken into the stomach, produce, soon af- 
ter, a sense of heat upon the surface of the body ; and, if 
the body be covered close and kept warm, a sweat is readi- 
ly brought out. The same medicines, taken during the 
cold stage of a fever, very often put an end to the cold 

* Simply as a diulent, water is undoubtedly the best drink than can be used, but by adding 
a small quantity of mucilage to it, two intensions are answered at the same time, viz. diluting 
and overcoming the acrimony ; hence the propriety of barley-waier, water-gruel, linsteed tea all 
made extremely weak ; ot very slight decoctions, of malt, of bread-crusts, or even the gelatinous 
parts of young animals, as calf's feel, or the more solid hartshorn shavings, tic. These animal 
substances must however, be used in great moderation, and only in those cases where the pa- 
tient requires nourishment. When this watery regimen is carried to a great length, the patient 
turns anasarcous; but this efTcci may be prevented by some of the neutral salts, of which Kali 
acetatum of the London Phannacopa-ia is most preferable, on account of its diuretic duality 
The do^e of it may be carried as far as half an ounce or six drachms in the day. The same in- 
tention may also be answered by eating water-cresses, radishc* li id season, or a little of the 
out rind of turnips ; all whicb are diuretics. 



PKACTICE OF PHYSIC. 7i 

c, and bring on the hot ; and they are also remarkable 
for stopping the vomiting which bo frequently attends the 
cold stage of fevers. All this shows, that neutral salts have 
a power of determining the blood to the surface of the bo- 
dy, and may therefore be of use in taking off the spasm 
which in fevers subsists there. 

160.] The neutral most commonly employed in fevers, 
is that formed of an alkali with the native acid of vegeta- 
bles,* but all the other neutrals have more or less of the 
same virtue ; and perhaps some of them, particulary the 
ammoniacal salts, possess it in a stronger degree. f 

161.] As cold water taken into the stomach, often shows 
the same diaphoretic effects with the neutral salts, it is pro- 
bable that the effect of the latter depends upon their refri- 
gerant powers mentioned above, (134.) What is the effect 
of the neutral salts, given when they are forming and in a 
state of effervescence ? It is probable that this circumstance 
may increase the refrigerant power of these salts, and may 
introduce into the body a quantity of fixed air ; but for 
these purposes it would seem proper to contrive that the 
whole of the effervescence should take place in the stomach. £ 

162.] A third means (153. 3) of determining to the sur- 
face of the body, and taking off the spasm subsisting there, 
is by the use of sudorific medicines, and of sweating. 

163.] The propriety of this remedy has been much disput- 
ed ; and specious arguments may be adduced both for and 
against this practice. 

In favor of the practice it may be said, 
J . That, in healthy persons, in every case of increased 
action of the heart and arteries, a sweating takes place, and 
is seemingly the means of preventing the bad effects of such 
increased action. 

* The following is the usual dose of it every three or four hours : 

R. Sal. Absinth. 9i. 

Succ. Limon. 3ss. vel. q. s. ad. saturationem ; 
Adde Aq. Fontanae giss- 
Syrup, commun. 3ii. 
M. f. haust. 

+ The form and-dose of this is the same with the foregoing, only using the volatile alkali in - 
stead of the fixed. The aqua ammonia acetala of the Loudon Pharmacopeia is one of the 
ammoniacal salts, and may be given in doses of two drachms every lour hours, diluted with an 
ounce and a halt ot waier. 

t It is certainly extremely useful in suppressing vomitings in fevers. The method of produc- 
ing the effervescence in the stomach is as follows : Let the patient take the auid first, diluted 
(vim a rafficienl quantity of water, and immediately after let him swallow the alkali, alsodilut- 
ed. The proportion of the alkali to the acid must be learned from chemistry. if the wild di- 
ed alkali is good, it wiU saturate about twelve tunes its weight of lemon juice. 



72 PRACTICE OF PHYSIC. 

2. That, in fevers, their most usual solution and termina- 
tion is by spontaneous sweating. 

3. That, even when excited by art, it has been found ma- 
nifestly useful, at certain periods, and in certain species of 
fever. 

164.] Upon the other hand, it may be urged against the 
practice of sweating, 

1. That as in fevers a spontaneous sweating does not im- 
mediately come on, so there must be in these some circum- 
stances different from those in a state of health, and which 
may therefore render it doubtful whether the sweating can 
be safely excited by art. 

2. That in many cases, the practice has been attended 
with bad consequences. The means commonly employed 
have a tendency to produce an inflammatory diathesis; 
which, if not taken off by the sweat following their use, 
must be increased with much danger. Thus, sweating em- 
ployed to prevent the accessions of intermitting fevers, has 
often changed them into a continued form, which is always 
dangerous. 

3. The utility of the practice is further doubtful, because 
sweating, when it happens, does not always give a final 
determination ; as must be manifest in the case of intermit- 
tents, as well as in many continued fevers, which are some- 
times in the beginning attended with sweatings that do not 
prove final; and, on the contrary, whether spontaneous or 
excited by art, seem often to aggravate the disease. 

165.] From these considerations, it is extremely doubt- 
ful if the practice of sweating can be admited very gener- 
ally ; but at the same time, it is also doubtful, if the failure 
of the practice, or the mischiefs said to have arisen from it, 
have not been owing to the improper conduct of the prac- 
titioner. With respect to this last, it is almost agreed 
among physicians, 

1. That sweating has been generally hurtful, when ex- 
cited by stimulant, heating, and inflammatory medicines. 

2. That it has been hurtful, when excited by much ex- 
ternal heat, and continued with a great increase of the heat 
of the body. 

3. That it is always hurtful, when it does not soon re- 
lieve, but rather increases, the frequency and hardness of 
the pulse, the anxiety and difficulty of breathing, the head- 
ach, and delirium. 

4. That it is always hurtful, if it be urged when the 



PRACTICE OF PHYSIC. 73 

sweat is not fluid, and when it is partial, and on the supe- 
rior parts of the body only. 

166.] In these cases, it is probable, that either an inflam- 
matory diathesis is produced, which increases the spasm 
on the extreme vessels ; or that, from other causes, the 
spasm is too much fixed to yield easily to the increased ac- 
tion of the heart and arteries ; and, upon either supposi- 
tion, it must be obvious, that urging the sweat, as ready to 
produce a hurtful determination to some of the internal 
parts, may be attended with very great danger. 

167.] Though the doubts started (164.) are to be attend- 
ed to ; and although the practices (165.) having been found 
hurtful, are therefore to be rejected; it still remains true, 

1. That sweating has certainly been often useful in pre- 
venting the accession of fevers, when the times of this have 
been certainly foreseen, and a proper conduct employed. 

2. That, even after fevers have in some measure come 
on, sweating, when properly employed, either at the very 
beginning of the disease, or during its approach and gra- 
dual formation, has often prevented their further progress. 

3. That, even after pyrexiae have continued for some 
time, sweating has been successfully employed in curing 
them, as particularly in the case of rheumatism. 

4. That certain fevers, produced by a very powerful 
sedative contagion, have been generally treated, so far a* 
we yet know, most successfully by sweating. 

168.] These instances (167.) are in favor of sweating, 
but give no general rule; and it must be left to further ex- 
perience to determine how far any general rule can be es- 
tablished in this matter. In the mean time, if the practice 
of sweating is to be attempted, we can venture to lay down 
the following rules for the conduct of it. 

1 . That it should be excited without the use of stimulant 
inflammatory medicines. 

2. That it should be excited with as little external heat, 
and with as little increase of the heat of the body, as possible. 

3. That when excited, it should be continued for a due 
length of time, not less then twelve hours, and sometimes 
for twenty-four or forty-eight hours ; always however, pro- 
viding that it proceeds without the circumstances mention- 
oncrf(165. 3. 4.) 

4. That for some part of the time, and as long as the per- 
son can easily bear, it should be carried on without admitting 
of sleep.* 

• This direction is tot always ataolutcljr nccessar>. 



74 PRACTICE OF PHYSIC. 

5. That it should be rendered universal over the whole bo- 
dy ; and, therefore, particularly, that care be taken to bring 
the sweating to the lower extremities. 

6. That the practice should be rendered safer by moderate 
purging, excited at the same time. 

7. That it should not be suddenly checked by cold any how 
applied to the body. 

169.] When attention is to be given to these rules, the 
sweating may be excited, 1. By warm bathing, or a fomen- 
tation of the lower extremities. 2. By frequent draughts of 
tepid liquors chiefly water, rendered more grateful by the 
addition of the light aromatic,* or more powerful by that 
of a small quantity of wine. 3. By giving some doses of 
neutral salts, f 4. Most effectually, and perhaps most safe- 
ly, by a large dose of an opiate, joined with a portion of neu- 
tral salts, and of an emetic. £ 

In what cases may cold water, thrown into the stomach 
in large quantities, be employed to excite sweating ? See 
Celsus, Lib. III. Cap. vii — ix. 

170.] The fourth means (153. 1.) of determining to the 
surface of the body, and thereby taking off the spasm affect- 
ing the extreme vessels, is by the use of emetics. 

171.] Emetics, and particularly antimonial emetics, have 
been employed in the cure of fevers ever since the introduc- 
tion of chemical medicines: but for a long time, they were 
employed by chemists and chemical practitioners only: and 
although of late the use of them has become very general, 
their efficacy is still disputed, and their manner of operating 
is not commonly explained. |j 

* The light aromatics here mentioned are sage, mint, halm, &c. For the purpose of sweat- 
in", while wines answer best, especially the thin fresh wines; as also Rhenish wines, particu- 
larly Hock. They must betaken warm and plentifully diluted. Wine whey is also a vetj 
powerful sudorific, asare also wheys made with vinegar, cream of tartar, the juices of acid fruits 
or with dulcified spirit of nitre. 

+ Neutral salts may be given in the quantity of two scruples ora drachm: but the patient 
must nevertheless dnnk large quantities of warm water. The tartarous tartarisalus is the neu- 
tral most frequently used for producing sweats ; its dose is generally one scruple, but it may be 
increased to two drachms. 

t This is the well known Dover's powder, now called in the London Pharmacopoeia, pulvis 
ipecacuanha? comnositus. It consists of eight parts of neutral salt, one of opium, and one of 
ipecacuhana ; so that 10 grains of it are an ordinary dose-- But it has been given to the quan- 
tity of a scruple without any bad consequences, and that dose repeated every two or three 
hours, till the effect was produced In general, however, doses of 12 or 15 grains are the most 
usual, and are found by experience tobe the best. The Dover's powder, when given in larger 
quamities/'often nauseates, and is rejected by vomit. In the Edinburgh Pharmacopoeia, the Do- 
ver's powder consists of 9 parts of neutral salt, one of opium, and one of ipecacuanha. The dose 
ef this, therefore, will be nearly the same as the dose of the former ; 1 1 grains of the Edinburgh 
Dover's powder being equivalent to 10 of the London, in administering this powder, it may be 
necessary to observe, that the patient ought to refrain from drinking for at least an hour after 
taking it, because it nauseates more readily if much diluted in the stomach ; and if the nausea 
be so great as to produce vomiting, its effects as a sudorific are considerably diminished : when, 
however, a sweat is produced, thin diluting drinks may and ought to be plentifullj given ; for in 
such cases, it is evident from the effect, that the medicine has passed out of the stomach, and 
that no material nausea can then be produced by it. 

II All the antimonial emetics are violent in their effects, and are sometimes attended with dis- 
agreeable consequences. Emetic tartar is found from experience to be the safen of them ; but 



PRACTICE OF PHYSIC. 75 

172.] Vomiting is, in many respects, useful in fevers ; 
as it evacuates the contents of the stomach ; as it emulges 
the biliary and pancreatic ducts ; as it evacuates the contents 
of the duodenum, and perhaps, also of a larger portion of 
the intestines ; as it agitates the whole of the abdominal vis- 
cera, cxpedes the circulation in them, and promotes their 
several secretions ; and lastly, as agitating also the viscera of 
the thorax, it has like effects there. All these several effects 
are in many cases and circumstances of fever, procured with 
advantage ; but do not properly fall under our view here, 
where we are to consider only the effect of vomiting in deter- 
mining to the surface of the body. 

173.] This effect we do not impute to the exercise of vom- 
iting in agitating the whole frame; but to the particular 
operation of emetics upon the muscular fibres of the stomach, 
whereby they excite the action of the extreme arteries on 
the surface of the body, so as thereby effectually to de- 
termine the blood into these vessels, remove the atony, and 
take off the spasm affecting them. 

174.] That such is the power of emetie, will appear from 
the several considerations mentioned above (44) ; and there- 
fore, that they are remedies well suited to the cure of fevers. 

175.] Emetics, for that purpose, are administered in two 
different ways : that is, either in such doses as may excite 
full and repeated vomitings ; or in such doses as may excite 
sickness and nausea only, with little or no vomiting at all. 

17G.] Full vomiting is best suited to the several purposes 
mentioned (172.) and is also well suited to determine to the 
surface of the body, so as thereby to obviate the atony and 
spasm which lay the foundation of fever. Thus vomiting, 
excited a little before the expected accession of the paroxysm 
of an intermittent, has been found to prevent the paroxysm 
altogether. And it has been observed also, that when con- 
tagion has been applied to a person, and first discovers its 
operation, a vomit given will prevent the fever, which was 
otherwise to have been expected. See Lind on Fevers and 
Infection. 

177.] These are advantages to be obtained by exciting 
vomiting at the first approach of fevers, or of the paroxysms 
of fevers ; and after fevers are formed, vomiting may also be 

it is not always of the same strength, unless peculiar attention be paid to the making of it. TI19 
prescription for it in the last Edinburgh Pharmacopoeia is preferable to that in the London. Some 
Cheinists think that it would be bettor to use boiling water alone, and omit the alkaline salt, ;d- 
ledging that the alkali renders the precipitation variable in point of strength : But this opinion 
is erroneous. The alkali is used in order to free the pi eci pit ate more completely from any ra» 
uiaiiis oi 1 lie muriatic acid, making it thereby a milder powderand a more perfect mix. 



76 PRACTICE OF PHYSIC. 

employed to take off, perhaps entirely, the atony and spasm, 
or at least to moderate these, so that the fever may proceed 
more gently and safely. 

178.] It is seldom, however, that vomiting is found to 
produce a final solution of fevers; and after they are once 
formed, it is commonly necessary to repeat the vomiting se- 
veral times; but this is attended with inconvenience, and 
sometimes with disadvantage. The operation of full vomit- 
ing commonly soon ceases, and the exercise of vomiting is 
often a debilitating power; and therefore, when the vomit- 
ing does not remove the atony and spasm entirely, it 
may give occasion to their recurring with greater force. 

179.] For these reasons, after fevers are fully formed, phy- 
sicians have thought proper to employ emetics in nauseating 
doses only. These are capable of exciting the action of the 
extreme vessels, and their operation is more permanent. At 
the same time, they often show their power by exciting some 
degree of sweat, and their operation is rendered more safe, 
by their commonly producing some evacuation by stool. 

180.] Such are the advantages to be procured by nauseat- 
ing doses of emetics ; and it only remains to mention, what 
are the medicines most fit to be employed in that manner, 
what are the most proper times for exhibiting, and what is 
the best manner of administering them. 

181.] The emetics at present chiefly in use, are, Ipeca- 
cuanha and Antimony. 

The former may be employed for every purpose of eme- 
tics, particularly those mentioned (172.) It may likewise be 
employed, either in larger or smaller doses for determining 
to the surface of the body ; but, even in very small doses, 
it so readily excites vomiting, as to be with difficulty em- 
ployed for the purpose of nauseating only ; and however 
employed there is reason to believe, that its effects are less 
permanent, and less powerfully communicated from the sto- 
mach to the rest of the system than those of Antimony. 

182.] This therefore, is generally preferred ; and its pre- 
parations, seemingly various, may all be referred to two 
heads; the one comprehending those in which the reguline 
part is in a condition to be acted upon by acids ; and there- 
fore, on meeting with acids in the stomach becomes active ; 
and the other comprehending those preparations in which 
the reguline part is already joined with an acid, rendering it 
active. 



PRACTICE OF PHYSIC, 77 

1 Of each kind there are great numbers, but not dif- 
fering essentially from one another. It will be enough for 
us to compare the Calx Antimonii Nitrata of the Edinburgh 
Dispensatory with the Emetic Tartar of the same. The for- 
mer, as I judge, is nearly the same with what is called 
James' Powder.* Which of these is best suited to the cure 
of fevers, as above explained, seems doubtful; but it appears 
to me, that, although the former may have some advan- 
tages from its slower operation, and may thereby seem to be 
more certainly sudorific and purgative, yet the uncertainty 
of its dose renders it inconvenient, has often given occasion 
to the timid to be disappointed, and to the bold to do mis- 
chief. On the other hand, the dose of the Emetic Tartar 
can be exactly ascertained; anil I think it maybe exhibited 
in such a manner as to produce all the advantages of the 
other. 

18-J..J Whichsoever of these preparations be employed, I 
judge the most proper time for exhibiting them, to be the 
time of accessions ; or a little before, when that can be cer- 
tainly known. In continued fevers, the exacerbations are 
not always very observable; but there is reason to think, 
that one commonly happens about noon, or soon after it, 
and another in the evening; and that these, therefore, are 
the most proper times for exhibiting emetics. 

185.] With respect to the manner of administration, that 
of the Calx Nitrata is simple, as the whole of what is judg- 
ed a proper dose is given at once, and no more can properly 
be given till the time, of the next accession. f 

The administration of the Emetic Tartar is different. It 
is to be given in small doses, not sufficient to excite vomiting; 
and these doses, after short intervals, are to be repeated for 
several times, till sickness, nausea, and some, but not much, 
vomiting, come on. The difference of this administration 
must depend upon the dose, and the length of the intervals at 
which it is given. If it be intended that the medicine should 
certainly operate by stool, the doses are made small, and 
the intervals long. On the contrary, when vomiting is pro- 
per, or when much purging ought to be avoided, and there- 

* The pulvis antimonialis of the London Pharmacopoeia is intended as a substitute for, or imi- 

Itmes' powder. The dose of it is 7 or 8 grains. It i>, by no means so sure in us ope- 

lations at the emetic tartar; yet it has been much extolled by several eminent modern pracii- 

+ 1 he <lo<e is ten or twelve grains. 'I his calx, hewever, is very uncertain in its operations, 
les acting with great violence, and sometimes scarcely producing anv perceptible 

eflectj. 



78 PRACTICE OF PHYSIC. 

fore some vomiting must be admitted, the doses are made 
larger and the intervals shorter.* 

186.] With respect to both kinds of preparations, the re- 
petition is to be made at the times of accession, but not very 
often: for if the first exhibitions duly managed, have little 
effect, it is seldom that the after exhibitions have much, and 
it sometimes happens that the repeated vomitings, and espe- 
cially repeated purges, do harm by weakening the patient. 

187.] The other set of internal medicines, ( 152. 2.) which 
I suppose may be useful in taking off the spasm of the ex- 
treme vessels, are those named Antispasmodic. How many 
of these may be properly employed, I am uncertain ; and 
their mode of operation is involved in great obscurity. It is 
certain, however, that opium, camphor, musk, and perhaps 
some others, have been employed in fevers with advantage ; 
but the circumstances in which they are especially proper 
and safe, I find difficult to ascertain ; and therefore cannot 
venture here to lay down any general doctrine concerning 
them. 

188.] The external means (151.) suited to take off the 
spasm of the extreme vessels, are blistering and warm 

BATHING. 

189.] What are the effects of Blistering, so frequently 
employed in fevers, is not yet agreed upon among physi- 
cians ; and many different opinions have been maintained on 
this subject, drawn not only from reasoning, but also from 
presumed experience. I must not, however, enter into 
controversy; but shall deliver my own opinion in a few 
words. 

190.] I am persuaded, that the small quantity of can- 
tharides absorbed from a blistering plaster, is not sufficient 
to change the consistence of the mass of blood ; and there- 
fore that such a quantity can neither do good, by resolving 
phlogistic lentor, if it exists; nor do harm, by increasing 
the dissolution of the blood arising from a putrid tendency iu 

* The dose of the Antimonium tartarisatum should never exceed three grains. The best 
method of givitii; it is. to dissolve three grains in six ounces of water ; and of this mixture give 
two table spoonfuls: if no vomiting ensues within twentv minutes, repeat the dose, and con- 
tinue to give a table spoonful every ten minutes, till the vomiting is excited, which must be 
encouraged by drinking plentifully of camomile tea, or a thin water gruel. It the emetic tar- 
tar be inte nded for a sudorific, two table spoonfuls of the following solution every two or three 
hours will perhaps be more proper than small doses of the other. 

R. Antimonii tartarisati gr. ii. 
Aq. Cinnamon. simpU §ii. 
— . Font. §vi. 
M. F. Julap. 



PRACTICE OF PHYSIC. 79 

it. I therefore neglect entirely the effects of cantharides 
upon the fluids. 

191.] The inflammation produced by the application of 
cantharides to the skin, affords a certain proof of their stim- 
ulant power ; but in many persons, the effect of that stim- 
ulus is not considerable ; in many it is not communicated to 
the whole system ; and even when the effect does take place 
in the whole system, it seems to be taken off entirely, by 
the effusion and evacuation of serum from the blistered part. 
I conclude, therefore, that neither much good is to be ex- 
pected, nor much harm to be apprehended, from the stim- 
ulant power of blistering ; and the certainty of this conclu- 
sion is established, by the great benefit arising from the pro- 
per practice of blistering in inflammatory diseases. 

J 92.] Much has been imputed to the evacuation occasion- 
ed by blistering ; but it is never so considerable as to affect 
the whole system ; and therefore can neither, by sudden de- 
pletion, relax the sanguiferous vessels, nor, by any revul- 
sion, affect the general distribution of the fluids. 

193.] The evacuation, however, is so considerable as to 
affect the neighboring vessels ; and the manifest utility of 
blistering near the part affected, in inflammatory diseases > 
leads me to believe, that blistering, by deriving to the skin, 
and producing an effusion there, relaxes the spasm of the 
deeper seated vessels. I apprehend it to be fn this manner, 
that the tumor of a joint, from an effusion into the cellular 
texture under the skin, takes off the rheumatic pain affect- 
ing that joint. 

194.] Analagous to this, it may be held, that the good ef- 
fects of blistering in continued fevers, arise from its relaxing 
the spasm of the extreme vessels, by a communication of 
the blistered part with the rest of the skin ; and this is illus- 
trated by the effect of blistering in eholic and dysentery. 

195.] It appears to me, that blistering may be employed 
at any period of continued fevers ; but that it will be of 
most advantage in the advanced state of such fevers, when 
the reaction being weaker, all ambiguity from the stimulant 
power of blistering is removed, and when it may best con- 
cur with other circumstances tending to a final solution of 
the spasm. 

196.] From the view of this matter given in (193. and 
194.) it will appear, that the part of the body to which blis- 
ter* ought to be applied, is indifferent, excepting upon the 



80 PRACTICE OF PHYSIC. 

suspicion of topical affection, when the blistering ought to 
be made as near as possible to the part affected. 

197.] Whether sinapisms and other rubefacients, act 
in a manner analogous to what we have supposed of blister- 
ing, may be doubtful ; but their effects in rheumatism, and 
other inflammatory diseases render it probable. 

198.J The other external means of taking off the spasm 
of the extreme vessels, is Warm Bathing. This was fre- 
quently, and in various circumstances, employed by the an- 
eients ; but till very lately has been neglected by modern 
physicians. As the heat of the bath stimulates the extreme 
vessels, and, with the concurrence of moisture, also relaxes 
them, it seems to be a safe stimulus, and well suited to take 
oif the spasm affecting them. 

199.] It may be applied to the whole bod}* by immersion ; 
but this is, in many respects, inconvenient; and whether 
some of the inconveniences of immersion might not be avoid- 
ed by a vapour-bath, I have not learned from experience. 
I know, however, from much experience, that most of the 
purposes of warm bathing can be obtained by a fomentation 
of the legs and feet, if properly administered, and continu- 
ed for a due length of time, which ought not to be less than 
an hour. 

200.] The marks of the good effects of such a fomentation, 
are, the patient's bearing it easily, its relieving delirium, 
and inducing sleep. 

201 .] Having now considered the several means of satisfy- 
ing the first general indication in the cure of fevers. I pro- 
ceed to the second (126.) which is, To remove the cause, or 
obviate the effects of debility. 

202.] Most of the sedative powers inducing debility, 
cease to act soon after they have been first applied; and, 
therefore, the removing them is not an object of our present 
indication. There is only one which may be supposed to con- 
tinue to act for a long time ; and that is, the contagion applied : 
but wc know nothing of the nature of contagion that can lead 
us to any measures for removing or correcting it. We know 
only its effects as a sedative power inducing debility, or as a 
ferment inducing a tendency to putrefaction in the fluids. 
The obviating the latter will be considered under our third 
general indication, and the former alone is to be considered 
here. 

203.] The debility induced in fevers by contagion, or 
other causes, appears especially in the weaker energy of the 



PRACTICE OF PHYSIC. 81 

brain ; but in what this consists, or how it may be directly 
restored, we do not well know. As nature, however, does 
.seemingly for this purpose, excite the action of the heart 
and arteries, we ascribe the continuance of debility to the 
weaker reaction or' the sanguiferous system ; so that the 
means to be employed for obviating debility, are immediate- 
ly directed to support and increase the action of the heart 
and arteries ; and the remedies used are tonics or stimu- 
lants. 

204.] In contagious diseases, both from the effects which 
appear, and from dissections, it is known that the tone of 
the heart and arteries is considerably diminished ; and that 
tonic remedies, therefore, are properly indicated. 

These are to be considered as of two kinds ; the first be- 
ing the power of cold, the second that of tonic medicines. 

205.] The power of cold, as a tonic, I have mentioned 
above; (90.) and it is employed, in fevers, in two ways; 
either as the cold matter is thrown into the stomach, or as 
it is applied to the surface of the body. 

206.] As it has been shown above, that the tonic power 
of cold can be communicated from any one part to every 
other part of the system ; so it will readily be allowed, that 
the stomach is a part as fit for this communication as any 
other; and that cold drink, taken into the stomach, mav, 
therefore, prove an useful tonic in fevers. 

207.] This the experience of all ages has confirmed ; but, 
at the same time, it has been frequently observed, that, in 
certain circumstances, cold drink, taken into the stomach, 
has proved very hurtful ; and, therefore, that the use of cold 
drink in fevers requires some limitations. What these limi- 
tations should be, and what are all the circumstances which 
may forbid the use of cold drink, is difficult to determine ; 
but it seems clearly forbidden, in all cases where a phlogistic 
diathesis prevails in the system, and more especially when 
there are topical affections of an inflammatory nature. 

208.] The other method of employing cold as a tonic, 
is, by applying it to the surface of the body. The appli- 
cation of cold air to the surface of the body, as a refrige- 
rant power fit to moderate the violence of reaction, I have 
spoken of above; (133.) but probably it may also be con- 
sidered here as a tonic, and useful in cases of debility. 

209.] Not only cool air, but cold water also, may be ap- 
plied to the surface of the body, as a refrigerant, and per- 
haps as a tonic. The ancients frequently applied it with 



82 PRACTICE OF PHYSIC. 

advantage, to particular parts, as a tonic ; but it is a disco- 
very of modern times, that in the case of putrid fevers, at- 
tended with much debility, the body may be washed all 
over with cold water. 

210.] This was first practised at Breslew in Silesia, as ap- 
pears from a dissertation, under the title of Epidcmia ver- 
na quce Wratislaviam, anno 1731, ajjlixit, to be found in 
the appendix to the Acta. Nat. Curios. Vol. X. And from 
other writers we find, that the practice has passed into some 
of the neighboring countries ; although in this island, so 
far as I know, we have hitherto had no experience of it. 

211.] The medicines which have been employed in fevers, 
as tonics, are various. If the Saccharum Saturni has been 
found useful, it is, probably, as a tonic, rather than as a 
refrigerant ; and the Ens Veneris, or other preparations of 
iron which have been employed, can act as tonics only. 
The preparations of copper, from their effects in epilepsy, 
are presumed to possess a tonic power ; but whether their 
use in fevers be founded upon their tonic or their emetic 
powers may be uncertain. The use of arsenic and of alum, 
in intermittent fevers, seems manifestly to depend upon their 
tonic power. And, upon the whole, there may occur cases 
of continued fevers, which may be cured by tonics taken 
from the fossil kingdom ; but the use of these has been rare, 
as well as the effects uncertain ; and physicians have era- 
ployed, more commonly, the vegetable tonics. 

212.] A great variety of these has been employed in the 
cure of intermittent fevers; but how many of them may be 
employed in continued fevers, or in what circumstances of 
these fevers is not well ascertained; audi shall now only 
consider the question with respect to the most celebrated of 
these tonics, the Peruvian Bark.* 

* When or how the inhabitants of Peru first discovered the febrifuge powers of this bark is 
involved in fable and uncertainty. They appear, however, to have long known its virtue 
although we have no proofs of their revealing it to the Europeans before the middle of the last 
century. The Spaniards call the tree winch produces it Palo de Calenturas, or fever tree Linne 
call, it Cinchona oficinnlil, in memory of the Countess of Cinchon, the Spanish viceroy's 
la-i; in Pe:u, who was the fi:st European that had been cured by it. It was first brought into 
Hal) by a Jesuit about the year 1649, and distributed through Europe by the fathers of that or- 
iler ; hence the names Cortexand Pulvis 'Jesuilicus, Putvii Patrum. By Cardinal de luen's i n - 
ilnence a cargo of it was procured and brought to Rome soon after ; whence it received the 
naitic- of Pulvis Cardinally dc Lugo. 

As this bark is a medicine of considerable importance, it may not be improper to join a short 
description of the external qualities of the best sort. It is in concave pieces, scarcely ever ex- 
ceeding the fourth pan or a cylinder cut longitudinally. It breaks short, and when broken evi- 
dently appears to be composed of three distinct and separate coats, viz. one outer thin coat 
that is somewhat rugged, often covered with moss of different kinds, and is of a reddish brown 
color like cinnamon. The middle coat is considerably thicker, of a closer texture and deener 
color than the first, and is less brittle but more resinous than any other part The third or in 
nermostcoat is woody and fibrous, and of a brighhsh red, at least considerably brighter than 
either of the others, from this description of the bark, great care must be taken in Dowderine 
it, not to leava much grosa powder, but to pass the whole of it through the sieve, because the 



PRACTICE OF PHYSIC. 83 

213.] This bark has been commonly considered as a spe- 
cific, or as a remedy of which the operation was not under- 
stood. But it is certainly allowable to inquire into this 
matter ; and I apprehend it may be explained. 

214.] To this purpose it is to be remarked, that as, ia 
many cases, the effects of the bark are perceived soon after 
its being taken into the stomach, and before it can possibly 
be conveyed to the mass of blood, we may conclude, that 
its effects do not arise from its operating on the fluids ; 
and must, therefore, depend upon its operating on the 
nerves of the stomach, and being thereby communicated 
to the rest of the nervous system. This operation seems to 
be a tonic power, the bark being a remedy in many case* 
of debility, particularly in gangrene ; and, as the recur- 
rence of the paroxyms of intermittent fevers depends upon 
a recurrence of atony, (35. and 36.) so probably the bark, 
by its tonic power, prevents the recurrence of these pa- 
roxysms ; and this is greatly confirmed by observing, that 
many other tonic medicines answer the same purpose. 

215.] If the operation of the bark may be thus explain- 
ed, from its possessing atonic power, it is easy to perceive 
why it is improper when a phlogistic diathesis prevails ; and 
from the same view, we can ascertain in what cases of con- 
tinued fever it may be admitted. These are either after 
considerable remissions have appeared, when it may be 
employed to prevent the return of exacerbations, on the 
same footing that it is used in intermittent fevers, or in the 
advanced state of fevers, when all suspicion of an inflamma- 
tory state is removed, and a general debility prevails in the 
system ; and its being then employed is sufficiently agree- 
able to the present practice. 

216.] With respect to the use of the bark, it is proper to 
add, that good effects are to be expected from it, almost 
only when given in substance and in large quantity.* 
217.] Another set of Medicines to be employed for ob- 

jnmt restlTOUS, and consequently the most effectual, part of the bark is the longest and most 
iifl'uult to powder. 

With respect to the two kinds of bark so much talked of and noticed a few years ago, it 
■aay be proper to observe, that they seem to be the production of the same tree. The Spaniards 
always selected such pieces as those above described out of the original packages, and rejected 
the thin, pale, and quilled sort, which the English preferred. H is certain that both the red, 
pale, quilled, and a variety of gradation between them, all occur in the same chest as originally 
imported ; and it is extremely improbable that the baik of different kinds of trees should be 

ricked together. Be this matter however as it may, experience gives the preference to what 
called the red hai k, and this sort ought surely to lie used. 

• The doses of the bark can only be determined trom the state of the patient's stomach and 
the violence of the disease : It is usual to give a drachm of the powder at a dose, and repeat 
it every two or three hours, according to the exigency of the case, or the state of the patient's 
bowels. It frequently passes oil bv stool when ^'iven too liberally; tnis ipsoavenienc* 1* obvi- 
ated by giving a few drops, V or I'/of laudanum, with each dose.' 



84 PRACTICE OF THYSIC. 

viating debility and its effects, are the direct stimulants 
(203.) These, in some measure, increase the tone of the mov- 
ing fibres ; but they are different from the tonics, as more di- 
rectly exciting and increasing the action of the heart and 
arteries. This mode of their operation renders the use of 
them ambiguous ; and when an inflammatory diathesis is 
present, as so often happens in the beginning of fevers, 
the effects of these stimulants may be very hurtful ; but it 
still remains probable, that in the advanced state of fevers, 
when debility prevails, they may be useful. 

218.] What are the stimulants that may be most pro- 
perly employed, I am uncertain, as the use of them in this 
age has been rare ; but I am disposed to believe that, of all 
kinds, wine is the best. 

219.] Wine has the advantage of being grateful to the 
palate and stomach, and of having its stimulant parts so 
'much diluted, that it can be conveniently given in small 
doses ; so that it may be employed with sufficient caution ; 
but it is of little service, unless taken pretty largely.* 

220.] It may be supposed, and on good grounds, that 
wine has an operation analogous to that of opium, and 
some other narcotic medicines. It may indeed be said, 
that we can distinctly mark its stimulant power only, which 
renders its effects in the phrenitic delirium manifestly hurt- 
ful, and, in the mild delirium, depending on debility, as re- 
markably useful. But in all this the analogy with opium 
is still obvious ; and it is probable, that both wine and opi- 
um are more useful by their sedative and antispasmodic, 
than by their stimulant powers. 

221.] These are the means of answering our second ge- 
neral indication ; (126. 2.) and I now proceed to the third, 
which is, To obviate or to correct the tendency of the fluids to 
putrefaction. 

222.] This may be done, 

1 . By avoiding any new application of putrid or putres- 
cent matter. 

2. By evacuating the putrid or putrescent matter alrea- 
dy present in the body. 

3. Bv correcting the putrid or putrescent matter remain- 
ing in the body. i 

* Wine is a valuable cordial, and is much superior to most other stimulants; it raises the 
pulse, supports the vis vitse, promoies diaphoresis, and resists putrefaction. With respect to the 
medical differences of wines, it may suffice to observe, that the effects of full bodied wines are 
more lasting than those of the thinner Red wines are subastringent, and consequently posses 
a tonic virtue, and are hence more proper in fevers of all kinds where wine is at all admissible, 
than white wines are. All sweet wines are nutritive and in general more stimulating thari 
others ; but they heat much and are apt to turn sour on the stomadr 



PRACTICE OF PHYSIC. 85 

4. By supporting the tone of the vessels, and thereby re- 
sisting further putrefaetion, or obviating its effects. 

223.] The further application of putrid or putrescent 
matter may be avoided, 

1 . By removing the patient from places filled with cor- 
rupted air. 

2. By correcting the air from which he cannot be re- 
moved. 

3. By preventing the accumulation of the patient's own 
effluvia, by a constant ventilation, and by a frequent change 
of bed-clothes and body linen. 

4. By the careful and speedy removal of all excremental 
matters from the patient's chamber. 

5. By avoiding animal food or correcting it. 

224.] The putrid or putrescent matter, already present 
in the body, may be evacuated partly by evacuating fre- 
quently the contents of the intestines,* and more effectual- 
ly still, by supporting the excretions of perspiration and 
urine, by the plentiful use of diluents. f 

225.] The putrid or putrescent matter, remaining in the 
body, may be rendered more mild and innocent by the use 
of diluents; or may be corrected by the use of antiseptics. 
These last are of many and various, kinds ; but which of 
them are conveniently applicable, or more particularly suit- 
ed to the case of fevers, is not well ascertained. Those 
most certainly applicable and useful, are, acescent aliments, 
acidsj of all kinds, neutral salts|| and fixed air.§ 

* The cvacuanrs to be used in these cases are, the milder purges, such as manna, &c. Rheu- 
barb and senna may also be used; but we matt avoid the drastic purges, such as jalap, scam- 
mony, jloes, and similar resinous purges. Calomel has been found very useful in these casesi 
It may be given to the quantity of 8 or 10 grains, and 3 ounces of the infusum senna 1 , wilhr 
fcalf an ounce of Glaubei's salt may be given, about 10 or 12 hours alter it, to accelerate its 
operation. 

+ The diluents necessary in these cases must all be mixt with a little port wine or claret. Warra 
port wine and water is ihe best diluent 

} Whether all kinds of acids are to be used as antiseptics is somewhat doubtful. The mineral 
acids, especially the vitriolic, have been much recommended; but the vegetable acids seem muda 
more efficacious. As their mildness allows us to give them in very large quantities, and as 
they mure easily enter into a union with the animal fluids than the fossile acids do, they seera 
more suitable antiseptics in these cases. Whether there is any difference between the native 
vegetable acids aud vinegar, with respect to their antiseptic qualities, was formerly much dis- 
puted by practitioners. Physicians, however, have now settled this question : and are generally 
of opinion, that in cases of putrescence ansing from fevers, the fermented acid is most" proper; 
but in cases of putrescence without fever, they prefer the native acid juices. 

II The antiseptic power of the different neutral salts is extremely various. According to the* 
reasoning in the foregoing note, those consisting pi a vegetable acid base ought to be preferred; 
and indeed experience confirm! the opinion. The Sptntus Mniderei i would perhaps be useful, 
il it could be prevented from passing two hastily off by sweat and urine. In doses of a drachm 
every two hours, it is less subject to promote sweat and urine, than when given in the usual dose 
•f half an ounce. Lemon juice, saturated widi volatile alkali, has often been successfully used 
iscs; especially when they are taken either in the act of effervescence, or separately, 
the one immediately after the other. 

i I'he anitseptic qualities of fixed air are much doubted by several eminent physicians. The 

giving it is frequently very difficult, and sometimes even impossible. The author might have 

iveral oilier antiseptics to the slioit list he has given i Wluit he has mentioned, however. 

are such aj ate generally used, or approved of by practitioners. Camphor is a considerable an* 

M 



ZG PRACTICE OF PHYSIC. 

226.] The progress of putrefaction may be considerably 
retarded, and its effects obviated, by supporting the tone 
of the vessels ; and this may be done by tonic remedies ; 
the chief of which are, Cold, and Peruvian Bark, both 
sufficiently treated of above, (205. et seq.) 

227.] I have now finished the consideration of the three 
general indications to be formed in the cure of continued 
fevers ; and have mentioned most of the remedies which 
have been, upon any occasion, employed in this business. 
It was necessary, in the first place, to consider these indica- 
tions and remedies separately, and to explain the operation 
of the latter more generally ; but from what has been now 
delivered, compared with what was said above, concerning 
the difference of fevers, and the signification of their seve- 
ral symptoms in forming the prognostic, I expect it will 
not be difficult to assign the indication, and to select and 
combine the several remedies mentioned, so as to adapt them 
to the several species and circumstances of continued fevers. 

I think it may be useful for my Readers to have the whole 
of the cure of continued fevers brought under one 
View, as in the following table. 

IN THE CURE OF CONTINUED FEVERS, 

THE INDICATIONS ARE, 

I. To moderate the violence of reaction. 

Which may be done by, 

1. Diminishing the action of the heart and arteries, by 
A. Avoiding or moderating those irritations which are almost 
constantly applied to the body ; as, 
a. The impressions made upon our senses, particularly, 
a. Increased heat, whether arising from 

tiseptic, but it is of too heating a quality to be given in such quantities as seem necessary. The 
common dose of it is from 1 to 10 grains, and it is best exhibited in the form of a bolus; in wl.icln 
form it may also be joined with some other antiseptic, as 

R. Camphor, gr. viii. 
Spt. Vini. gutt. x. 
Pulv. Rad. Contrayerv. 9ii. 
Syr. Simpl. q. s. 
M. f. bol. 

Thrs dose may be repeated every 6 hours, or oftencr, especially if the pulse be low or weak In 
using camphor the practitioner ought to remember that this medicine, when given in lar«e 
quantities, frequently occasions delirium. Peculiar attention muit therefore be paid to that 
symptom, and the doses of camphor regulated with caution. 



PRACTICE OF PHYSIC. Si 

aa. External heat, or\ 

/3£. The accumulation of the heat of the body. 

b. The exercise of the body, 

c. The exercise of the mind, 

d. The taking in of aliment, 

e. Particular irritations arising from 
a. The sense of thirst, 

&. Crudities, or corrupted humors, in th* stomach, 
y. The preternatural retention of faeces, 
£ A general acrimony of the fluids. 

B. Employing certain sedative powers ; as, 

a. Cold, 

b. Refrigerants ; the chief of which are, 
c. Acids of all kinds, 

£. Neutral salts, 
y. Metallic salts. 

C. Diminishing the tension and tone of the arterial system, by 

a. Blood-letting, 

b. Purging. 

2. Taking off the spasm of the extreme vessels, by 

A. Internal means ; which are, 

a. Those remedies which determine to the surface, as, 
a. Diluents, 

/?. Neutral salts, 
y. Sudorifics, 
£. Emetics. 

b. Those remedies named antispasmodics. 

B. External means ; as, 

a. Blistering, 

b. Warm bathing. 

II. To remove the causes, or obviate the ejects , of 
debility, by 

1. Supporting and increasing the action of the heart and art** 
ries, by 
A. Tonics, as, 

a. Cold, 

b. Tonic medicines, which are either, 
a. Fossil, as, 

aa. Saccharum saturni, &c. or, 
/3. Vegetable, as, 
«a. Peruvian Bark. 
J3. Stimulants, as, 

a. Aromatics, &c. 
bv Wine. 



es PRACTICE OF PHYSIC. 

III. To obviate or correct the tendency of the fluids to ' 
■putrefaction, by 

1. Avoiding the application of putrid or putrescent matter, by 

A. Removing the patient from places filled with corrupted air. 

B. Correcting the air, from which he cannot be removed. 

C. Avoiding the accumulation of the patient's own effluvia, by 

a. A constant ventilation, 

b. Frequently changing the bed-clothes and body-linen. 

D. Removing carefully and speedily all excremental matters. 

E. Avoiding animal food, or correcting it. 

2. Evacuating the putrid or putrescent matter already piesent 

in the body, by, 

A. Evacuating frequently the intestines. 

B. Supporting the excretions of perspiration and urine, by 

a. Diluents, 

b. Neutral salts. 

3. Correcting the putrid or putrescent matter remaining in the 

body, by 

A. Diluents, 

B. Antiseptics, 

C. Fixed air. 

4. Resisting farther putrefaction, or obviating its effects, by- 
Supporting the tone of the vessels, by 

Tonic remedies. 



SECTION II. 
Of the Cure of Intermittent Fevers. 

228.] IT still remains to consider the cure of intermit- 
tent fevers; and with respect to these, we form also three 
general indications. 

1. In the time of intermission, to prevent the recurrence 
of paroxysms. 

2. In the time of paroxysms, to conduct these so as to ob- 
tain a final solution of the disease. 

3. To take off certain circumstances which might prevent 
the fulfilling of the two first indications. 

229.] The first indication may be answered in two ways; 

1. By increasing the action of the heart and arteries some 
time before the period of accession, and supporting that in- 
creased action till the period of the accession be over, so 
as thereby to prevent the recurrence of the atony and spasm 



PRACTICE OF PHYSIC. 39 

of the extreme vessels which give occasion to the recur- 
rence of paroxysms. 

2. Without increasing the action of the heart and arte- 
ries, the recurrence of paroxysms may be prevented, by 
supporting the tone of the vessels and thereby preventing 
atony, and the consequent spasm. 

230.] for the purpose mentioned in 229. 1. the action of 
the heart and arteries may be increased, 

1. By various stimulant remedies, internally given, or 
externally applied, and that without exciting sweat. 

2. By the same remedies, or others so managed as to ex- 
cite sweating, and to support that sweating till the period 
of accession be for some time past. 

3. By nauseating doses of emetics, given about an hour 
before the time of accession, thereby supporting and in- 
creasing the tone and action of the extreme vessels. 

231.] The tone of the extreme vessels may be supported 
without increasing the action of the heart and arteries (229. 
2.) by various tonic medicines ; as, 

1. Astringents alone. 

2. Bitters alone. 

3. Astringents and bitters conjoined. 

4. Astringents and aromatics conjoined. 

5. Certain metallic tonics. 
C. Opiates. 

Lastly, an impression of horror. 

A good deal of exercise, and as full a diet as the condi- 
tion of the patient's appetite and digestion may allow of, 
will be proper during the time of intermission, and may be 
considered as belonging to this head. 

232.] Of all the tonic remedies mentioned (231.) the 
most celebrated, and perhaps the most certainly effectual, 
is the Peruvian bark, the tonic power of which we have en- 
deavored to demonstrate above (214.) and have at the same 
time explained its use in continued fevers. 

The same observation as made in 216. is especially pro- 
per in the case of intermittents : and further, with respect 
to these, the following observations or rules are offered here. 

1 . That the bark may be employed with safety at any 
period of intermittent fevers, providing that, at the same 
time, there be neither a phlogistic diathesis prevailing in the 
system, nor any considerable or fixed congestion present 
in the abdominal viscera. 

2. The proper time for exhibiting the bark in intermit- 



00 PRACTICE OF PHYSIC. 

tent fevers, is during the time of intermission; and where 
intermissions are to be expected, it is to be abstained from 
in the time of paroxysms. 

3. In remittents, though no entire apyrexia occurs, the 
bark may be given during the remissions; and it should be 
given even though the remissions be inconsiderable, if, 
from the known nature of the epidemic, intermissions 
or considerable remissions, arc not to be soon expected, 
and that great danger is apprehended from repeated ex- 
acerbations. 

4. In the case of genuine intermittents, while a due quan- 
titv of bark is to be employed, the exhibition of it ought to 
be brought as near to the time of accession as the condition 
of the patient's stomach will allow. 

6. In general, in all cases of intermittents, it is not suf- 
ficient that the recurrence of paroxysms be stopped for 
once by the use of the bark ; a relapse is commonly to be 
expected, and should be prevented by the exhibition of the 
bark, repeated at proper intervals.* 

*Tlie quantity of bark to be given in the intermission must be as great as the stomach can pos- 
sibly bear. It is very common to give 2 ounces during the intermission, in doses of half a drachm 
or two scruples every hour, especially in quartans, But it has been found more successful in its 
operations, when we begin with small doses, viz. one scruple in the commencement of the in* 
termissions, and increase the dozes to onS drachm towards the ehd of it. The bark sometimes 
sits better on the stomach by adding to it about an eighth or a fourth of its weight of some aro- 
matic antiseptic. Virginian snake root answers this intention very well. An ounce of red baik 
and 2 drachms of snake root taken during the intermission of a tertian, if the stomach can bear 
it, or if no diarrhoea comes on, generally prevents the next paroxism. In case of diarrhoea being 
produced by bark, ten or twelve drops of laudanum are to be given three or four times with 
each dose or the bark. The substances generally joined with the bark in prescription, seem cal- 
culated either to promote its efficacy or reduce it to the intended form, without having re- 
gard to the aereeableness of the composition. This, however, is a point of great consequence, as the 
taste of the bark, and the large quantity of it necessary for the cure, make the patient frequently 
loath it before its use ought to be discontinued. When made inio an electuary or bolus with sy- 
rups, it sticks about the mouth and fauces ; whence its taste remains a long while ; but when 
made into an electuary with mucilage, it passes down freely, scarcely leaving any taste behind 
it. The taste of the bark is very effectually concealed by liquorice root in a decoction, «r by the 
extract in an electuary. The extract of logwood also conceals the taste of the bark, and an elec- 
tuary made with it, and a sufficient quantity of mucilage, is a very elegant form. Decoctions, 

• u u, iiiis, and tinctures of the bark are much less efficacious than'the substance. The extract 

• i I the resin are seldom employed in the cure of intermittents, except when other forms will 
ii.; sit on the stomach. The fonnula in the last London Pharmacopoeia is the best, being a com- 

I of both the extract and resin ; for the watery extract is strong in bitterness, but weak in 
sslrirtgency, and the resin is strong in astrtngency,'but weak in bitterness, and both qualities are 
necessary for curing intermittents. About 10 or 12 grains of the extract are equivalent to half a 
drachm of the powder. When a paroxysm has been stopped by the bark, it is by no means safe to 
■ ii the use of this medicine altogether, as a t elapse is always to be apprehended. The doses 
; iually to be diminished, and the intervals between the limes of giving them are to be in- 
creased : After tertians, we may diminish the quantity daily one half, till we arrive at 2 drachms ; 
•-e 2 drachms ought to be continued in doses of 'l scruples thrice a day for eight days ; after 
period, 2 scruples ought to be given night and morning for a week 'longer: after quar- 
tans, when tl>e dose is reduced to two drachms a day. it will be prudent to continue giving this 
quantity daily for a fortnight, and half a drachm night and morning for a fortnight longer. In 
'uder the more effectually to prevent a relapse, great attention must be paid to diet and regi- 
men. Patients are generally extremely voracious after the cure of intermittents; and indeed 
quire considerable nutrition to supply the waste occasioned by the fever. Small quan- 
tities of food are to be taken at Once and to be often repeated ; and the must nutritive, and at 
lie time, easily digestable food, must be chosen, as broths with barley and white flesh meat, 
roast lamb, vea!, chickens, new laid eggs, broiled fresh fish, &c. Acrid, acescent, and irritating 
ailments, and acids ate to be carefully avoided. The drink ought to be in moderate quantit)', 
but rich and strong ; as mild ale, jiort wine and water. With respect to the regimen proper for 
convalescents from intermittents, it may suffice to observe, that sleep may be indulged in. Ex- 
rithoul fatigue is of great use, either by walking, by riding on horseback, or in a carriage, 



PRACTICE OF PHYSIC. o, 

233.] Our second general indication for conducting the 
paroxysms of intermittent fevers, so as to obtain a final so- 
lution of the disease, may be answered, 

1. By exhibiting emetics during the time of the cold 
stage, or at the beginning of the hot. 

2. By opiates given during the time of the hot stage.* 
234.] The circumstances which may especially prevent 

the fulfilling of those too indications, and therefore give 
occasion to our third, are a phlogistic diathesis prevailing 
in the system, and congestions fixed in the abdominal vis- 
cera. The first must be removed by blood-letting and 
the antiphlogistic regimen ; the second by vomiting and 
purging. 

Where these measures are not immediately effectual, 1 
hold it safer to attempt the cure of the disease by the 
means pointed out in general in 229, rather than by those 
in article second of the same paragraph. 

according to the strength of the patient. But above all, cold must be carefully avoided ; for no- 
thing more effectually produces a relapse than animprudent exposure to cold damp air, or a 
neglect in keeping the body properly clothed. The practice of saving purges after the cure of 
intermittents is highly blameable, and is frequently the cause of a relapse. Should costiveness 
be troublesome, it may be removed by very mild emollient glysters. 

* This practice of giving vomits in the end of the cold siage and an opiate after their opera- 
tion, is old. It is mentioned by Sydenham, Boerhaave, Van Swieten, and most practical wri- 
ters. It must not, however, be indiscriminately used. It is seldom attended with any salutary 
effect, except in vernal intermittent^, and in the earlier periods of the disease ; and it is constant- 
ly attended with disadvantage when the disease has been of long continuance. 



BOOK II. 

OF INFLAMMATIONS, OR PHLEGMASIA. 



CHAPTER I. 

€)F INFLAMMATION IN GENERAL. 

SECTION I. 

Of the Phenomena of Inflammation. 

235.] TT7HEN any part upon the surface of the body is 
VV affected with unusual redness, heat, paiu and 
tumor, we name the disease an Inflammation or Phlegma- 
sia. These symptoms of inflammation are never consider- 



32 PRACTICE OF PHYSIC. 

able, without the whole system being, at the same time, af- 
fected with pyrexia. 

236.] As the external, so likewise the internal parts may 
be affected with inflammation; and we judge them to be so, 
when, together with pyrexia, there is a fixed pain in any 
internal part, attended with some interruption in the exer- 
cise of its functions. 

237.] We judge of the presence of inflammation also 
from the state of the blood drawn out of the veins. When 
the blood, after cooling and concreting, shows a portion of 
the gluten separated from the rest of the mass, and lying; 
on the surface of the crassamentum; as such separation 
happens in all cases of more evident phlegmasia ; so, in 
ambiguous cases, we, from this appearance, joined with 
other symptoms, infer the presence of inflammation. At 
the same time, it must be observed that as several cir- 
cumstances in blood-letting, may prevent this separation 
of gluten from taking place in blood otherwise disposed to 
it; so, from the absence of such appearance, avc cannot 
always conclude against the presence of inflammation. 

238.] I cannot easily give any other general history of 
the phenomena of inflammation than what is contained in 
the three preceding paragraphs ; and the variations which 
may take place in its circumstances, will occur to be more 
properly taken notice of under the several heads of the par- 
ticular genera and species to be hereafter mentioned, I pro- 
ceed, therefore, to inquire into the proximate cause of in- 
flammation in general. 



SECTION II. 
Of the Proximate Cause of Inflammation. 

239.] The phenomena of inflammation (235.) all concur 
in showing, that there is an increased impetus of the blood 
in the vessels of the part affected ; and as, at the same 
time, the action of the heart is not always evidently increas- 
ed, there is reason to presume, that the increased impetus 
of the blood in the particular part is owing especially to 
the increased action of the vessels of that part itself. 

240.] The cause of this increased action in the vessels of 
a particular part is, therefore, what we are to consider as 
the proximate cause of inflammation. 



PRACTICE OF PHYSIC. 93 

In many cases, we can manifestly perceive, that inflam- 
mation arises from the application of stimulant substances 
to the part. When the application of such stimulants, 
therefore, is evident, we seek, for no other cause of inflam- 
mation ; but as, in many cases, such application is neither 
evident, nor, with any probability, to be supposed, we 
must in such cases, seek for some other cause of the increas- 
ed impetus of the blood in the vessels of the part. 

241.] Many physicians have supposed, that an obstruc- 
tion of the extreme vessels, any how produced, may prove 
a cause of inflammation ; and particularly, that this may 
arise from an obstruction formed by a matter stopping up 
these vessels. But many difficulties attend this doctrine.* 

1 . The opinion seems chiefly to have arisen from the ap- 
pearance of the blood described in (237.) when the sepa- 
rated gluten was considered as a preternatural and morbid 
matter; but we now know very certainly, that this gluten 
is constantly a constituent part of the human blood ; and 
that it is only a peculiar separation of the parts of the 
blood that happens in consequence of inflammation and 
some other circumstances, which gives occasion to the ap- 
pearance that was falsely considered as a mark of a mor- 
bid lentor in the blood. 

2. There are no experiments directly in proof of a pre- 
ternatural lentor prevailing in the mass of blood; nor is 
there any evidence of certain parts of the blood occasion- 
ally acquiring a greater density and force of cohesion than 
ordinary; neither is there any proof of the denser or more 
Coherent parts being present in the mass of blood, in such 
greater proportion than usual, as to occasion a dangerous 
spissitude. The experiments of Dr. Browne Langrish on 
this subject afford no conclusion, having been made on 
certain parts of the blood separated from the rest, without 
attending to the circumstances of blood-letting, which very 
much alter the state- of the separation and corjcretion of the 
blood drawn out of the veins. 

3. The supposition of a preternatural lentor or viscidity 
of the blood, is not well founded ; for it is probable, that 
nature has specially provided against a state of the fluids, 
so incompatible with the exercise of the most important 
functions of the animal economy. While motion continues 
to prevent any separation of parts, and heat continues to 

« This is the Boerhaavian doc-trine which the author here refutes, many objections might be 
maiie a r this refutation ; but toexamine it minutely, is foreign to my piu, 

|iu>e, and would require more room than the narrow limits uf these notes c»n possibly allow, 

X 



11 PRACTICE OF PHYSIC. 

preserve the fluidity of the more viscid, there seems to "bff 
always so large a proportion of water present as to give a 
sufficient fluidity to the whole. 1 must own that this is not 
absolutely conclusive ; but I still repeat it, as giving a pro- 
bability to the general argument. 

4. In the particular case of inflammation, there are se- 
veral circumstances which render it probablethat the blood 
is then more fluid than usual. 

5. I presume that no such general lentor, as Boerhaave 
and his disciples have supposed, does ever take place ; be- 
cause if it did, it must shew more considerable effects than 
commonly appear. 

6. Besides the supposition of an obstructing lentor, phy- 
sicians have supposed, that an obstruction may be formed 
by an impermeable matter of another kind, and that such 
an obstruction may also be the cause or* inflammation. 
This supposition is what is well known in the schools un- 
der the title of an error loci ; but it is an opinion that 1 
cannot find to be at all probable ; for the motion of the 
blood in the extreme vessels is so weak and slow, as rea- 
dily to admit a retrograde course of it; and therefore, if 
a particle of blood should happen to enter a vessel whose 
branches will not allow of its passage, it will be moved 
backward:?, till it meet with a vessel fit for transmitting it ; 
and the frequent ramifications and anastomoses of the ex- 
treme arteries are very favorable to this. I must own in- 
deed, that this argument is not absolutely conclusive; be- 
cause I allow it to be pretty certain that error loci, does 
actually upon occasion happen ; but for the reasons I have 
given, it is probable that it seldom happens, and is there- 
fore rarely the cause of inflammation ; or if it be, that it 
is not merely by the obstruction that it produces ; as, 
among other reasons, I conclude particularly from the fol- 
lowing argument. 

7. Though an obstruction should be supposed to take 
place, it will not be sufficient for producing the effects, 
and exhibiting the phenomena, that appear in inflamma- 
tion. The theory that has been commonly employed on 
this occasion is by no means satisfying ; and, in fact, it 
appears, from many observations and experiments, that 
considerable obstructions may be formed, and may sub- 
sist, without producing the symptoms of inflammation. 

242.] Obstruction, therefore, from a matter stopping up 
the vessels, Gaub. Pathol, 249. i. is not to be considered as 



PRACTICE OF PHYSIC. 9i 

the primary cause of inflammation ; but at the same time, 
his sufficiently probable, that some degree of obstruction 
does take place in every case of inflammation. The dis- 
tension, pain, redness and tumor, attending inflammation, 
fire to be explained only by supposing, that the extremities 
of the arteries do not readily transmit the unusual quantity 
of blood impelled into them by the increased action in the 
course of these vessels. Such an obstruction may be sup- 
posed to happen in every case of an increased impetus, of 
the blood ; but it is probable, that in the case of inflamma- 
tion, there is also a preternatural resistance to the free pas- 
sage of the fluids. 

243.] From the doctrine of fever, we are led to believe, 
that an increased action of the heart and arteries is not sup- 
ported for any length of time by any other means than a 
spasm affecting the extreme vessels ; and that the same spasm 
takes place in inflammation seems likely, because that eve- 
ry considerable inflammation is introduced by a cold stage, 
and is accompanied with that and other circumstances of 
pyrexia. It seems also probable, that something analo- 
gous to this occurs even in the case of those inflammations 
which appear less considerable, and to be purely topical. 

244.] From all this, the nature of inflammation may in 
many cases be explained in the following manner. Some 
causes of inequality in the distribution of the blood may 
throw an unusual quantity of it upon particular vessels, to 
which it must necessarily prove a stimulus. But, further, 
it is probable, that, to relieve the congestion, the vis ?nc- 
dicatfix natura increases still more the action of these ves- 
sels ; and which, as in all other febrile diseases, it effects 
by the formation of a spasm on their extremities. 

245.] A spasm of the extreme arteries, supporting an 
increased action in the course of them, may therefore be 
considered as the proximate cause of inflammation ; at least, 
in all cases not arising from direct stimuli applied ; and 
even in this case" the stimuli may be supposed to produce a 
spasm of the extreme vessels. 

.J That, in inflammation, there is the concurrence 
of a constriction of the extreme vessels, with an increased 
action in the other parts of them, seems probable, from the 
consideration of Rheumatism. This is a species of inflam- 
mation which is often manifestly produced, either by cold 
applied to over distended vessels, or by causes of an in- 
creased impetus, and over distention in vessels previously 



95 PRACTICE OF PHYSIC. 

constricted. Hence the disease especially appears at sea- 
sons liable to frequent and considerable vicissitudes of heat 
and cold. 

To this we may add, that the parts of the body most fre- 
quently affected with inflammation, are those exposed, both 
to over distention, from a change in the distribution of the 
fluids, and, at the same time, to the immediate action of 
cold. Hence, quinsies, and pneumonic inflammations, are 
more frequent than any others. 

247.] That a spasm of the extreme vessels takes place in 
inflammation, is to be further presumed from what is at the 
same time the state of the whole arterial system. In every 
considerable inflammation, though arising in one part only, 
an affection is communicated to the whole system, in conse- 
quence of which an inflammation is readily produced in 
other parts beside that first affected. This general affection 
is well known among physicians, under the name of the 
diathesis phlogistic a. It appears most commonly in 
persons of the most rigid fibres : is often manifestly indu- 
ced by the tonic or astringent powers of cold ; is increased 
by all tonic and stimulant powers applied to the body ; is 
always attended with a hardness of the pulse ; and is most 
effectually taken off* by the relaxing power of blood-letting. 
From these circumstances, it seems probable, that the dia- 
thesis phlogistica consists in an increased tone, or contracti- 
lity, and perhaps in an increased contraction of the muscu- 
lar fibres of the whole arterial system. Such a state of the 
system seems often to arise, and subsist for some time, with- 
out the apparent inflammation of any particular part ; but 
such a state of the system renders it likely, that a spasm may 
at the same time readily arise in any of the extreme vessels, 
and a particular inflammation be there produced. It does, 
however, appear also, that the general diathesis frequently 
arises from inflammation begun in a particular part. 

248.] I have thus endeavored, in the case of inflamma- 
tion, to explain the state of the whole system, as well as that 
of the part more particularly affected. The latter I have 
considered as when in its first formation ; but after it has 
subsisted for some time, various changes take place in the 
part affected ; and of these I must now take notice. 



PRACTICE OF PHYSIC. 97 



SECTION III. 

Of the Terminations of Inflammation. 

249.] IF an inflammation be cured while the state and 
texture of the part remain entire, the disease is said to bo 
terminated by resolution. 

This happens when the previous congestion and spasm 
have been in a moderate degree, and the increased impetus 
of the blood has been sufficient to overcome the spasm, to 
dilate the vessels and to remove the congestion so that the 
part is restored to its ordinary and healthy state. 

A resolution takes plaee also when the increased impetus 
of the fluids has produced an increased exhalation into the 
adjoining cellular texture, or an increased excretion in 
some neighboring- part, and lias thereby relaxed the spasm, 
and relieved the congestion, in the vessels of the part more 
particularly affected. 

Lastly, A resolution may take place, when the increased 
impetus of the blood in the whole system occasions an eva- 
cuation, which, though in a distant part, may prove suffi- 
cient to take off the phlogistic diathesis of die whole system, 
and thereby relieve the congestion and spasm of the parti- 
cular part affected by inflammation. 

250.] The tumor which appears in inflammation may be 
imputed in part to the congestion of fluids in their proper 
vessels ; but is owing chiefly to an effusion of matter into the. 
adjoining cellular texture ; and, accordingly, tumors sel- 
dom appear but in parts adjoining to a lax cellular texture. 
If, in this case, the matter effused be only a larger quantity 
of the ordinary exhaling fluid, this, when the free circula- 
tion in the vessels is restored, will be readily absorbed, and 
the state of the part will become the same as before. But, 
if the increased impetus of the blood in an inflamed part, 
dilate the exhalant vessels to such a degree, that they pour 
out an entire serum, this will not be so readily reabsorbed; 
and, from the experiments of Sir John Pringle, and espe- 
cially from those of Mr. Gaber, Miscell. Taurin. Vol. II. 
we learn, that the serum, under stagnation, may suffer a 
particular change, by having the gluten present in it chang- 
ed, into a white, opaque, moderately viscid, mild liquor* 



£»3 PRACTICE OF PHYSIC. 

which we name pus. When this change takes place in the 
inflamed part, as it is at the same time attended with an 
abatement of the redness, heat, and pain, which before dis- 
tinguished the inflammation, so the disease is said to be ter- 
minated by suppuration ; and an inflamed part, contain- 
ing a collection of pus, is called an abscess. 

251.] In inflammation, the tendency of it to suppura- 
tionmay be discovered by the long continuance of the in- 
flammation, without the symptoms of resolution ; by some 
remission of the pain of distention ; by the pain becoming of 
a throbbing kind, more distinctly connected with the pul- 
sation of the arteries being fuller and softer; and often by 
the patient's being frequently affected with cold shiverings. 
The period at which this takes place is not determined, 
but may be sometimes sooner, sometimes later. When the 
tendency is determined, the time necessary to a complete 
suppuration is different in different cases. 

When pus is completely formed, the pain in the part 
entirely ceases, and a weight is felt in it. If the collection 
be formed immediately under the skin, the tumor be- 
comes pointed, the part becomes soft, and the fluctuation 
of the fluid within can commonly be perceived; while at 
the same time, for the most part, the redness of the skin 
formerly prevailing is very much gone. 

252.] In abscesses, while the pus is formed of one part 
of the matter which had been effused, the other and thin- 
ner parts are reabsorbed, so that in the abscess, when open- 
ed, a pus alone appears. This pus, however, is not the 
converted gluten alone ; for the conversion of this being 
the effects of a particular fermentation, which may affect 
the solid substance of the part, and perhaps every solid of 
animal bodies; so it most readily, and particularly, effects 
the cellular texture, eroding much of it, which thereby 
becomes a part of the pus. It generally happens also, that 
some of the smaller red vessels are eroded, and thereby 
some red blood often appears mixed with the pus in absces- 
ses. Upon the whole, the internal surface of an abscess 
is to be considered as an ulcerated part. 

253.] This account of suppuration explains, why an ab- 
scess, when formed, may either spread into the cellular 
texture of the neighboring parts ; or by eroding the incum- 
bent teguments, be poured out upon the surface of the bo- 
dy, and produce an open ulcer. 

25 ■!■.] We have here given the idea of an abscess as a 



PRACTICE OF PHYSIC. 99 

collection of matter following inflammation ; but the term 
has been applied to every collection of matter effused, and 
changed by stagnation in an inclosed cavity. 

The matter of abscesses, and of the ulcers following 
them is various, according to the nature of what is effused, 
and which may be, 

J. A matter thinner than serum. 

2. An entire and pure serum. 

3. A quantity of red globules. 

4. A matter furnished by particular glands seated in the 
part. 

5. A mixture of matters from different sources, changed 
by peculiar fermentation. 

It is the second only which affords a proper pus ; the ef- 
fusion whereof, whether in suppurating parts or ulcers, 
seems to be the peculiar effect of an inflammatory state of 
the vessels ; and for this reason it is, that, when ulcers do 
not produce a proper pus, a circumstance always absolute- 
ly necessary to their healing, we in many cases, bring the 
ulcers to a state of proper suppuration, by the application 
of stimulants exciting inflammation, such as balsams, 
mercury, copper, &c. 

255.] When the matter effused into the cellular texture 
of an inflamed part, is tainted with a putrid ferment, this 
produces in the effused matter, a state approaching more 
or less to that of putrefaction. When this is in a mode- 
rate degree, and effects only the fluids effused, with the 
substance of the cellular texture, the part is said to be af- 
fected with gangrene ; but if the putrefaction affect also 
the vessels and muscles of the part, the disease is said to be 

a SPHACELUS. 

256.] A gangrene, and its consequences, may arise from 
a putrid ferment diffused in the mass of blood, and poured 
out with the serum effused, which it operates upon more 
powerfully while the serum is stagnant, and retained in the 
beat of the body : but it may also arise from the peculiar na- 
ture of the matter effused being disposed to putrefaction ; 
as particularly seems to be the case of the red globules of 
the blood effused in a large quantity. In a third manner 
also, a gangrene seems frequently to arise from the violent 
excitement of the inflammation destroying the tone of the 
vessels ; whereby the whole fluids stagnate and run into pu- 
trefaction, which taking place in any degree, destroys still 
further the tone of the vessels, and spreads the gangrene. 



100 PRACTICE OF PHYSIC. 

257.] In inflammation, the tendency to gangrene may be 
apprehended from an extreme violence of pain and heat in 
the inflamed part, and from a great degree of pyrexia at- 
tending the inflammation. 

The actual coming on of gangrene may be perceived by 
the color of the inflamed part changing from a clear to a 
dark red ; by blisters arising upon the part ; by the part be- 
coming soft, flaccid, and insensible ; and by the ceasing of 
all puin while these appearances take place. 

As the gangrene proceeds, the color of the part becomes 
livid, and by degrees quite black ; the heat of the part en- 
tirely ceases ; the softness and flaecidity of the part increase; 
it loses its consistence, exhales a cadaverous smell, and may 
then be considered as affected with sphacelus. 

258.] Gangrene is thus a third manner in which inflam- 
mation terminates ; and the schools have commonly marked 
8 fontrth termination of inflammation ; whicfe is, by a scir- 
rhous, or an indolent hardness of the part formerly affected 
with inflammation. This however, is a rare occurrence, 
and does net seem to depend so much upon the nature of 
inflammation, as upon the circumstances of the part affected. 
It is in glandular parts chiefly that scirrhosity is observed ; 
and it is probably owing to the parts readily admitting a 
stagnation of the fluids. I have observed, that inflamma- 
tion seldom induces scirrhus ; but that this more commonly 
arises from other causes; and when inflammation supervenes, 
which it is sooner or later apt to do, it does not so common- 
ly increase, as change the scirrhosity into some kind of ab- 
scess. From these considerations it does not seem necessary 
to take any further notice of scirrhus as a termination of in- 
flammation. 

259.] There are, however, some other terminations of 
inflammation, not commonly taken notice of, but now to 
be mentioned. 

One is, by the effusion of a portion of the entire mass of 
blood, either by means of rupture or of anastomosis, into 
the adjoining cellular texture. This happens especially in 
inflammations of the lungs, where the effused matter, by 
compressing the vessels, and stopping the circulation, oc- 
casions a fatal suffocation ; and this is perhaps the manner 
in which pneumonic inflammation most commonly proves 
fatal. 

260.] Another kind of termination is, that of certain 
inflammations on the surface of the body, when there is 



PRACTICE OF PHYSIC. j 01 

poured out under the cuticle a fluid, which being too gross 
to pass through its pores, therefore separates it from the 
skin, and raises it up into the form of a vesicle containing 
the effused fluid ; and by which effusion the previous in- 
flammation is taken off. 

261. J Beside these already mentioned, I believe there is 
still another manner in which inflammation terminates. 
When the internal parts are affected with inflammation^ 
there seems to have been almost always upon their surface, 
an exudation, which appears partly as a viscid concretion 
upon their surface ; and partly as a thin serous fluid effused 
into the cavities in which the inflamed viscera are placed. 
Though we have become acquainted with these appearances 
only, as very constantly accompanying those inflammations 
which have proved fatal, it is however probable, that like 
circumstances may have attended those which were termi- 
nated by resolution, and may have contributed to that event. 
It is in favor of this supposition that there are instances of 
pneumonic inflammation terminatir' in a hydrothorax. 



SECTION IV. 
Of the Remote Causes of Inflammation. 

262.] THE remote causes of inflammation may be re- 
duced to five heads. 

1 . The application of stimulant substances ; among which 
are to be reckoned the action of fire, or burning. 

2. External violence operating mechanically in wound- 
ing, bruising, compressing, or overstretching the parts. 

3. Extraneous substances, lodged in any part of the bo- 
dy, irritating by their chemical acrimony or mechanical 
form, or compressing by their bulk or gravity. 

4. Cold, in a certain degree, not sufficient immediately 
to produce gangrene. 

5. An increased impetus of the blood determined to a 
particular part. 

It will not be difficult to understand how these remote 
causes, singly, or in concurrence, produce the proximate 
cause of inflammation. 

263.] It does not appear, that in different cases of inflam- 
mation, there is any difference in the state of the proximata 

o 



\02 PRACTICE OF PHYSIC. 

eause, except in the degree of it ; and though some differ- 
ence of inflammation may arise from the difference of the- 
remote causes, yet this is not necessary to be taken notice 
of here ; because the different appearances which attend 
different inflammations may be referred, for the most part,, 
to the difference of the part affected ; as will appear when 
we shall consider the several genera and species marked in 
the Nosology. When I come to treat of these, I shall find 
a more proper occasion for taking notice of the different 
states of the proximate, or of the differences of the remote 
cause, than by treating of them in general here. 



SECTION V. 

Of the Cure of Inflammation. 

264.] THE indications of cure in inflammation are dif- 
ferent, according as it r$ay still be capable of resolution, o;? 
may have taken a tendency to the several other terminations 
above mentioned. As the tendency to these terminations 
is not always immediately evident, it is always proper, upon 
the first appearance of inflammation, to attempt the cure of 
it by resolution. For this purpose, the indications of cure 
are, 

1 . To remove the remote causes, when they are evident, 
and continue to operate. 

2. To take, off the phlogistic diathesis affecting either the 
whole system, or the particular part. 

3. To take off the spasm of the particular part, by re- 
medies applied either to the whole system, or to the part 
itself. 

265.] The means of temoving the remote causes will 
readily occur, from considering the particular nature and 
circumstances of the different kinds. Acrid matters must 
> be removed, or their action must be prevented, by the ap- 
plication of correctors or demulcents.* Compressing and 
overstretching powers must be taken away ; and, from their 
several circumstances, the means of doing so will be obvious. 

* If the matter causing the inflammation be an acid, then the application of an alkaline sub- 
stance will be proper : If, on the contrary, the inflammation be produced by an alkali, then an 
musi be applied. In many rases, however, the acrid substances causing inflammation 
aie neither alka.ine nor acid : and, in such cases, or when we cannot lind a proper corrector, 
x v.e mu>t use demulcents, which by their obtundin? quality, sheath the actimony, or jititaj. 
^ths parts to which *hc-y. are applied from being irritated or ewrodtoV 



PRACTICE OF PHYSIC. 103 

266.] The means of taking off the phlogistic diathesis 
*)f the system, are the same with those for moderating the 
violence of reaction in fever, which are mentioned and 
treated of from (127 to 159,) and therefore need not be re- 
peated here. I only observe, that in the use of those reme- 
dies, there is less occasion for any reserve than in many 
cases of fever ; and more particularly, that topical bleed- 
ings* are here particularly indicated and proper. 

267.] The means of taking off the spasm of the parti- 
cular part are nearly the same as those mentioned above, for 
taking off the spasm of the extreme vessels in the case of 
fever, and which are treated of from (150. to 200.) Only 
it is observed here, that some of these are here especially 
indicated, and that some of them are to be directed more 
particularly to the part especially affected ; the management 
of whicn will be more properly considered when we shall 
treat of particular inflammations. f 

268.] When a tendency to suppuration (251.) is distinct- 
ly perceived, as we suppose it to depend upon the effusion 

•The advantages of topical bleedings, inmost cases of local inflammation are very great. 
They may be pertormed By cupping, or what is in many cases more preferable, by letches. 
Cupping acts sometimes as a stimulus, especially on parts which arc tendonous or "^shy, or 
where the cellular substance is thin, and thus frequently increases the inflammation which we 
would wish to resolve. 

+ The resolution of an inflamed part is considerably assisted by the application of discutt- 
ents; and in most cases when the general system is not affected, these discuticnts alone fre- 
quently succeed in dissolving an incipient phlegmon. Solutions of lead in vinegar arc the ap- 
plications which the best modern practitioners generally approve. Goulard's extract was sup- 
posed by the vulgar to be a new remedy ; and his panegv ric on it, tended in a considerable 
degree to render the use of lead mere universal than it had been before his time. Tin-re arc, 
however, roanv weighty objections against the formula used by that gentleman; the chief one 
is, that on account of the different strength of the vinegar employed, :iml of the degree of he.it 
Used in the process, we can never accurately ascertain the quantity of lead dissolved in the: 
acid ; and consequently the efficacy of this preparation must be uncertain. The Saccharurn 
Saturni, which is always of the same strength, is therefore prefei able to Goulard's extract : and 
as vinegar is a powarful discutient itself, it has been u^ual to add a quantity of vinegar l» 
the solution of the sugar of lead in distilled water. The following proportions have beca 
found iu general to be the best : 

R. Sacchar. Saturn. 31. 
Acet. Gallic, opt. §iv. 
Aq. font, distillatx 5xxxii. 
M. 

In the application of this solution, it is of great consequence that the parts affected should he 
continually moistened with it. Poullices made of fresh breadcrumb, and as much of the above 
solution as is necessary, are in general preferable to any other mode of applying II; but it 
sometimes happensthat the inflamed part is so extremely painful and tender, as not to near 
the great weight of a poultice ; and in such cases we must have recourse to pieces of soft ltnen, 
moistened with the solution. Both these applications) viz. poultices, or wet pledgets, must al- 
ipplied cold, and be frequently renewed when they become waim, hard or stiff. This, 
is ihe must approved method of applwng, lead for the purpose of resolving inflammations; yet 
it frequently happens that practitioners meet with patients whose prepossessions for a popular 
remedy are so great that there is no persuading them from using it. The method of making 
Goulard's extract and Vegeto-Mineral Water are therefore subjoined, 

Take Litharge of Gold, one pound, 

French White-Wine Vinegar, a quart, 
Boil them in an earthen vessel, on a slow tire, for an hour and an half, constantly stirrin? them 
with a wooden spalhula, and when cold, pour off the clear liquor, which rnu<t he kept inj weu 
stopped jum phials. The Vegeto-Mineral water is made bv adding a hundred droys ot lbs 
above extract (o a quait uf water, and four wa-spooniuls of French laandf. 



104 PRACTICE OF PHYSIC. 

of a fluid which cannot be easily reabsorbed, so it becomes 
necessary that this fluid be converted into pus, as the only 
natural means of obtaining its evacuation ; and as the effu- 
sion is, perhaps, seldom made without some rupture of the 
vessels, to the healing of which a pus is absolutely neces- 
sary ; so, in the case of a tendency to suppuration, the 
indication of cure always is, to promote the production of 
a perfect pus as quickly as possible. 

269.] For this purpose, various remedies, supposed to 
possess a specific power, have been proposed ; but I can per- 
ceive no such power in any of them; and in my opinion, 
all that can be done is, to favor the suppuration by such 
applications as may support a proper heat in the part, as 
by some tenacity, may confine the perspiration of the part, 
and as, by an emollient quality, may weaken the cohesion 
of the teguments, and favor their erosion.* 

270.] As, in the case of certain effusions, a suppuration 
is not only unavoidable, but desirable, it may be supposed, 
that most of the means of resolution formerly mentioned 
should be avoided ; and accordingly our practice is com- 
monly so directed. But as we observe, on the one hand, 
that a certain degree of increased impetus, or of the origi- 
nal circumstances of inflammation, is requisite to produce 
a proper suppuration ; so it is then especially necessary to 
avoid those means of resolution that may diminish too much 
the force of the circulation. And as, on the other hand, 
the impetus of the blood, when violent, is found to prevent 
the proper suppuration ; so, in such cases, although a ten- 

* Poultices of various kinds have been recommended for this purpose. It is however, of 
little consequence what their ingredients are, provided they be emollient, and applied warm. 
The white bread poultice is in common use, and answers in general very well ; the addition of 
a little oil keeps it from becoming hard, and is at the same time serviceable as an emollient. 
A poultice of bruised lintseed well boiled with milk and water is strongly recommended by 
some writers, and indeed not without reason, on account of its very great emollient quality. 

As heat is absolutely necessary for the production of matter in tumors, it is of great conse- 
quence that the poultices should not be suffered to cool on the part, and that they should be 
©fien renewed. Mr. Bell has given excellent directions for applying poultices, with the inten- 
tion of promoting suppuration. 

" Warm fomentations and poultices, (says that rational practitioner) are the means usually 
employed for the application of heat to an inflamed part ; and when these are regularly and 
frequently renewed, nothing, it is probable, can more effectually answer the purpose. But in 
the ordinary manner in which they are applied, and as the cataplasms are renewed only once, 
or at most twice a day, they must always, it is imagined, do more harm than good. For at 
loon as the degree of heat they at first possessed is dissipated, the moisture kept up by them, 
with the consequent evaporation that ensues, must always render the part much colder than if 
it had been merely wrapped up in flannel, without the use of any such application. 

" In order to receive all the advantages of such remedies, the part affected should be well 
fomented with flannels, pressed out of any warm emollient decoction, applied as warm as the 
patient can easily bear them, continued at least half an hour at once, and repeated four or five 
times a day. 

" Immediately after the fomentation is over, a lar?e emollient poultice should likewise be 
applied warm, and renewed every second or third hour at farthest. Of all the lorms recom- 
mended for emollient cataplasms, a common bread and milk poultice, with a due .proportion of 
butter or oil, is perhaps the most eligible ; as it not only possesses all the advantages of i\w 
•tbers, but caa at all times be more easily prgcured."— Treatise on Ulcers, Edition of 1787, p 67. 



PRACTICE OF PHYSIC. iq$ 

tfency to suppuration may have begun, it may be proper to 
continue those means of resolution which moderate the force 
of the circulation. 

With respect to the opening of abscesses, when com- 
pletely formed, I refer to the writings on surgery.* 

271.] When an inflammation has taken a tendency to 
gangrene, that event is to be prevented by every possible 
means; and these must be different, according to the na- 
ture of the several causes occasioning that tendency, as 
may be understood from what has been already said of 
them. After a grangrene has, in some degree, taken place, 
it can be cured only by the separation of the dead from 
the living parts. This, in certain circumstances, can be 
performed by the knife, and always most properly, when 
it can be so done. 

In other cases, it can be done by exciting a suppuratorv 
inflammation on the verge of the living part, whereby its 
cohesion with the dead may be every where broken off, so 
that the latter may fall off by itself. While this is doino-, 
it is proper to prevent the further putrefaction of the part, 
and its spreading wider. For this purpose, various anti- 
septic applications have been proposed: But it appears to 
me, that, while the teguments are entire, these applications 
can hardly have any effect; and, therefore, that the fun- 
damental procedure must be to scarify the part so as to 
reach the living substance, and, by the wounds made there, 
to excite the suppuration required. By the same incisions 
also, we give access to antiseptics, which may both pre- 
vent the progress of the putrefaction in the dead, and ex- 
cite the inflammation necessary on the verge of the livino- 
part.f 

• For a particular account of knowing when abscesses are completely formed, at what period 
Ihey ought to be opened, and the manner of opening them, the reader can consult no author 
preferable to Mr. Bell. 

+ The author mentioned in the preceding note treats this subject in his usual rational man- 
ner, and with no less perspecuity than judgment. Contrary to the opinion of all former wri- 
ter! on gangrene, he disapproves of scarifications, and the subsequent application of antiseptics 
and stimulants. Mr. Bell's reasoning against this practice is to the following purport : The de- 
gree of inflammation requisite, and indeed necessary, for the separation of the dead parts, w 
only very slight, and when too violent, it fails to produce the denied elfcct. Scarifications, and 
the sub-equcnt application of stimulants, which increase the inflammation too much, are there- 
fore hurtful Again, in scantying, there is a considerable risk of wounding large blood vessel^ 
nerves or tendons ; besides the disadvantage of allowing the putrescent fluids of the gangrene 
to enter more freely the sound parts, by increasing the surface of the wound. With respect to 
the application of antiseptics, it is justly remarked, that although these medicines have the qui- 
itty of preserving dead animal substances from corruption, they by no means produce th:- same 
etfect on living animal substances. But the concluding argument is of much greatei weight, 
vk. that, in a long course of extensive practice, no advantages ever accrued from scarification. 

These objections against promiscuous scarification were first proposed by Mr. Bell in hisTrea- 
tise on Ulcors, about 12 years ago; and the novelty of the opinion excited the attention of al- 
most every practitioner. At present, however, it is universally adopted, and would of it-elf, 
independunt of the many improvements Mr. Bell has made in surcerv, perpetuate his justly ac- 
qtocd fame. * 



105 PRACTICE OF PHYSIC. 

272.] When the gangrene proceeds from a loss of tone; 
v and when this, communicated to the neighboring parts, 
prevents that inflammation which, as I have said, is neces- 
sary to the separation of the dead part from the living ; 
it will be proper to obviate this loss of tone, by tonic medi- 
cines given internally; and, for this purpose, the*' Peru- 
vian bark has been found to be especially effectual. That 
this medicine operates by atonic power, 1 have endeavor- 
ed to prove above, (214.) and from what is said in 215. 
the limitations to be observed in employing it may also be 
learned. When the gangrene arises from the violence of 
inflammation, the bark may not only fail of proving a 
remedv, but may do harm: and its power as a tonic is 
especially suited to those cases of gangrene which proceed 
from an original loss of tone, as in the case of palsy and 
oedema; or to those cases of inflammation where a loss 
of tone takes place, while the original inflammatory 
symptoms are removed^* 

273.] The other terminations of inflammation either dp 
not admit of any treatment, except that of preventing them 
by the means of resolution ; or they belong to a treatise of 
surgerv, rather than to this place. 

Having thus, therefore, delivered the general doctrine, 
J proceed now to consider the particular genera and species 
of inflammation. 

It has been hinted above (263.) that the difference of in- 
flammation arises chiefly from the difference of the part 
affected : I have .therefore arranged them as they are cu- 
taneous, visceral, or articular; and in this order they 
are now to be considered. 



CHAPTER II. 



OF INFLAMMATION, MORE STRICTLY 
CUTANEOUS. 

274.] /"CUTANEOUS inflammations are of two kinds, 
V>* commonly distinguished by the names of 

PHLEGMON and ERYSIPELAS. 

* The bark must be given in these cases in large quantities ; and as the pulse is in general 
very small, Port wine must be used along with it. Beside the use of these remedies, a good 
nourishing diet is absolutely requisite, with such a quantity of strong generous wine as is suffi- 
cient to keep up the pulse, and induce the necessary slight degree of inflammation. When in- 
deed the patient is extremely languid, and much /educed, the warm stimulating cordials, as 
camphor, confectio cardiaca, spiritus aroraaticus voUulis, &c. may be used with advantage. 



PRACTICE OF PHYSIC. ioi 

Of the latter there are two cases, which ought to be dis- 
tinguished by different appellations. When the disease is 
an affection of the skin alone, and very little of the whole 
system, or when the affection of the system is only symptom- 
atical of the external inflammation, I shall give the disease 
the name of erythema ; but when the external inflamma- 
tion is an exanthema, and symptomatica! of an affection of 
the whole system, I shall then name the disease erysipelas.* .. 

275.] It is the erythema only that I am to consider here. 

For the distinction between Erythema and Phlegmon, I 
have formerly referred to the characters given of them iiv 
our Nosology. See Synops. Nosolg. Meth. Vol. II. p. 5. 

fren. vii. spec. 1. and 2. But I think it proper now to de- 
iver the characters of them more fully and exactly here, as- 
follows. 

A phlegmon is an inflammatory affection of the skin, with 
a swelling, rising generally to a more considerable eminence 
in the middle of it ; of a bright red color ; both the swel- 
ling and color being pretty exactly circumscribed ; the 
whole being attended with a pain of distention, often of a 
stounding or throbbing kind, and frequently ending in sup- 
puration~ 

An Erythema, Rose, or St. Anthony's fire, is an inflam- 
matory affection of the skin, with hardly any evident swel- 
ling ; of a mixed and not very bright red color, readily 
disappearing upon pressure, but quickly returning again ; 
the redness of no regular circumscription, but spreading 
unequally and continuing almost constantly to spread upon 
the neighboring part ; with a pain like to that from burning ; 
producing blisters, sometimes of a small, sometimes of a 
larger size ; and always ending ia a desquamation of th« 
scarf-skin, sometimes in gangrene. 

This subject I am not to prosecute here, as properly be- 
longing to surgery, the business of which I am seldom to> 
enter upon in this work ; and shall therefore observe only 
a9 necessary here, that the difference of these appearances 
seems to depend on the different seat of the inflammation. 
In the phlegmon, the inflammation seems to affect especially 
the vessels on the internal surface of the skin communicating 
with the lax subjacent cellular texture ; whence a more 
copious effusion, and that of serum convertible into pus, 
takes place. In the erythema, the inflammation seems to 
have its seat in the vessels on the external surface of thei 

* The Erjsintlas I' ra't}culur»? dswittwa in ?rtr«le GQ6» c«r<w 



JO* PRACTICE OF PHYSIC. 

skin, communicating with the rete mucosum, which, does 
not admit of any effusion, but what separates the cuticle, 
and gives occasion to the formation of a blister, while the 
smaller size of the vessels admits only the effusion of a thin 
fluid, very seldom convertible into pus. 

Besides these differences in the circumstances of these two 
kinds of inflammation, it is probable that they also differ 
with respect to their causes. Erythema is the effect of all 
kinds of acrids externally applied to the skin ; and, Avhen 
arising from an internal cause, it is from an acrimony, pour- 
ed out on the surface of the skin under the cuticle. In the 
phlegmon an acrimony is not commonly evident. 

276.] These differences in the seat and causes of the 
phlegmon and erythema being admitted, it will be evident, 
that when an erythema affects any internal part, it can take 
place in those only whose surfaces are covered with an epi„ 
thelion, or membrane analogous to the cuticle. 

277.] The same distinction between the seat and causes 
of the two diseases will, as I judge, readily explain what 
has been delivered by practical writers, with respect to the 
cure* of these different cutaneous inflammations. But I 
shall not, however, prosecute this here, for the reason 
given above; (275.) and, for the same reason, shall not 
say any thing of the variety of external inflammation, that 
might otherwise be considered here.f 



CHAPTER III. 

OF OPHTHALMIA, OR INFLAMMATION OF 
THE EYE. 

278.] HHHE inflammation of the eye may be consider-* 
J. ed as of two kinds; according as it has its 
seat in the membranes of the ball of the eye, when I would 
name it ophthalmia membranarum ; or as it has its seat 
in the sebaceous glands placed in the tarsus, or edges of 
the eyelids, in which case it may be termed ophthalmia 

TARSI. 

* The method of curing an erysipelas is delivered in article 708, et sequent. 

+ The cure of erythema is chiefly effected by the antiphlogistic regimen already luflicientlr 
described. Although bleeding, purging, and the general remedies for resolving an inflamma- 
tion, will in most cases, cure an erythema, yet at it is a disease frequently depending on a pe- 
cuiar acrimony, we shall always find great advantage from the external use of emollients ap- 
j>led cold, or mucilaginous diluents taken internally. The disease, however, is seldom dancer- 
«Ui, and generally terminates favorably. * 



PRACTICE OF PHYSIC. 109 

These two kinds are very frequently combined together, 
as the one may readily excite the other; but they are still 
to be distinguished according as the one or the other may 
happen to be the primary affection, and properly as they 
often arise from different causes. 

2T9.] The inflammation of <the membranes of the eye, 
affects especially, and most frequently, the adnata, appear- 
ing in a turgescence of its vessels ; so that the red vessels 
which are naturally there, become not only increased in 
size, -but there appear many more than did in a natural 
state. This turgescence of the vessels is attended with 
pain, especially upon the motion of the ball of the eye; 
and this like every other irritation applied to the surface 
of the eye, produces an effusion of tears from the lachry- 
mal gland. 

This inflammation Commonly, and chiefly, affects the 
adnata spread on the anterior part of the bulb of the eye ; 
but usually spreads also along the continuation of that 
membrane on the inside of the palpebrse 5 and as that is 
extended on the tarsus palpebrarum, the excretories of the 
sebaceous glands opening there are also frequently affect- 
ed. When the affection of the adnata is considerable, it 
is frequently communicated to the subjacent membranes of 
the eye, and even to the retina itself, which thereby ac- 
quires so great a sensibility, that the slightest impression 
of light becomes painful. 

280.] The inflammation of the membranes of the eye is 
in different degrees, according as the adnata is more or 
less affected, or according as the inflammation is either of 
the adnata alone, or of the subjacent membranes also ; and 
upon these differences, different species have been establish- 
ed, and different appellations given to them. But I shall 
not, however, prosecute the consideration of these, being 
of opinion, that all the cases of the Ophthalmia membra- 
narum differ only in degree, and are to be cured by reme- 
dies of the same kind, more or less employed. 

The remote causes of Ophthalmia are many and vari- 
sus; as, 

1 . External violence, by blows, contusions, and wounds, 
applied to the eyes ; and even very slight impulses applied, 
whilst the eyelids are open, to the ball of the eye itself, 
are sometimes sufficient for the purpose. 

2. Extraneous bodies introduced under the eyelids, ei~ 



no PRACTICE OF PHYSIC. 

ther of an acrid quality, as smoke and other acrid vapors,* 
or of a bulk sufficient to impede the free motion of the 
eyelids upon the surface of the eyeball. 

3. The application of strong light, or even of a mode- 
rate light long continued. 

4. The application of much heat, and particularly of 
that with moisture. 

5. Much exercise of the eyes in viewing minute objects. 

6. Frequent intoxication. 

7. Irritation from other and various diseases of the eyes. 
S. An acrimony prevailing in the mass of blood, and 

deposited in the sebaceous glands on the edges of the eye- 
lids. 

9. A change in the distribution of the blood, whereby 
either a more than usual quantity of blood, and with more 
than usual force, is impelled into the vessels of the head, 
or whereby the free return of the venous blood from the 
\-essels of the head is interrupted. 

10. A certain consent of the eyes with the other parts 
of the system, whereby from a certain state of these parts, 
either a simultaneous, or an alternating affection of the 
eyes, is produced. 

281.] The proximate cause of Ophthalmia, is not dif- 
ferent from that of inflammation in general ; and the dif- 
ferent circumstances of Ophthalmia may be explained by 
the difference of its remote causes, and by the different 
parts of the eye which it happens to affect. This may be 
understood from what has been already said ; and I shall 
now therefore proceed to consider the cure. 

282.] In the cure of Ophthalmia, the first attention will 
by always due to the removing of the remote causes, and 
the various means necessary for this purpose will be direct- 
ed by the consideration of these causes enumerated above. 

The Ophthalmia membranarum requires the remedies 
proper for inflammation in general; and when the deeper 
seated membranes are affected, and especially when a py- 
rexia is present, large general bleedings may be necessary. 
But this is seldom the case; as the Ophthalmia, for the 
most part, is an affection purely local, accompanied with 
little or no pyrexia. General bleedings, therefore, from 
the arm or foot, have little effect upon it; and the cure is 
chiefly to be obtained by topical bleedings, that is, blood 

* Hence chemists, when much employed in processes where copious noxious vapors arise, 
ought to De extreme':, eyeful to avoid them in much a* possible. 



PRACTICE OF PHYSIC. Ill 

drawn from vessels near the inflamed part ; and opening 
the jugular vein or the temporal artery, may be consider- 
ed as in some measure of this kind. It is commonly suf- 
ficient to apply a number of leeches* round the eye; and 
it is perhaps better still to draw blood from the temples, 
by cupping and scarifying. f In many cases, a very effec- 
tual remedy is, that of scarifying the internal surface of 
the inferior eyelid ; and more so still, is cutting the turgid 
vessels upon the adnata itself.J 

283.] Besides blood-letting, purging, as a remedy suit- 
ed to inflammation in general, has been considered as pe- 
culiarly adapted to inflammations in any of the parts or the 
head, and therefore to Ophthalmia; and it is sometimes 
useful ; but, for the reasons given before with respect to 
general bleeding, purging in the case of Ophthalmia does 
not prove useful in any degree in proportion to tiie evacu- 
ation excited. 

234.] For the relaxing the spasm in the part, and taking 
off the determination of the fluids to it, blistering near the 
part has commonly been found useful. § 

285.] Electrical sparks taken from the eye will often 
suddenly discuss the inflammation of the adnata ; but the 
effect is seldom permanent, and even a frequent repetition 
seldom gives an entire cure. 

286.] Ophthalmia, as an external inflammation, admits 
of topical applications. All those, however, that increase 
the heat and relax the vessels of the part, prove common- 
ly hurtful; and the admission of cool air to the eye, the 
proper application of cold water immediately to the ball 
of the eye, and the application of various cooling and 
astringent medicines, which at the same time do not pro- 

* Ten or twelve may be applied at once, and when many are employed together, they gene- 
rally produce a better ertect, than if fewer be employed repeatedly : That is twelve ai once are 
more efficacious than three at a time repeated four limes a day. 

+ Cupping and scarifying the temples ought to be performed with very great caution, because 
of the numerous ramifications of considerable branches of arteries in those places. 
} I hese ((Derations require great nicety. Vor the particular method of performing them, tlve 

referred lo the writers on Surgery. 
Much harm ensues from these operations when injudiciously performed : they ought there- 
ined from, except when a very skillful and expert surgeon can be procured, 
seldom serviceable, except thev be repeated several times. Caning the vessels of die 
pel haps the best preventative of an opacity of the Cornea thai we know : and where- 
ver there is the least tendency to an opacity, (he practice should be put in execution. The ope- 
ration ought lo be repeated daily tor iwo, three, or four weeks, or even longer, if a cure i» nut 
accomplished sooner. 
i The part where blisters are usually applied in Ophthalmia are behind the ear, or the nap« ot 
rs ought to be kepi open by die subsequent application of the mild blisier- 
lintxnent, ii they assume appearances of healing. 

in die neck are sometimes recommended ; but where speedy relief is required, they ate 

»il little seldom begin to discharge nil the expiration ot a few da>s ; besides 

thev are extremely troublesome to the patient : and if the phlogistic diati e -i- be considerable, 

ne so exceedingly iutlamed as to pieduuc many disagreeable circumstances 

ll at might have been avoided. 



112 PRACTICE OF PHYSIC. 

duce much irritation, prove generally useful; even spiritu- 
ous liquors, employed in moderate quantity, have often 
been of service.* 

287.] In the cure of Ophthalmia, much care is requisite 
to avoid all irritation, particularly that of light ; and the; 
only safe and certain means of doing this is by confining the 
patient to a very dark chamber. 

288.] Thi?se are the remedies of the Ophthalmia mem- 
branarum ; and in the Ophthalmia tarsi, for as it is produ- 
ced by Ophthalmia membranarum, the same remedies may 
be necessary. As, however, the Ophthalmia tarsi may 
often depend upon an acrimony deposited in the sebaceous 
glands of the part, so it may require various internal reme- 
dies according to the nature of the acrimony in fault ; for 
which I must refer to the consideration of scrophula, syphilis, 
or other diseases with which tins Ophthalmia may be con- 
nected ; and when the nature of the acrimony is not ascer- 
tained, certain remedies, more generally adapted to the 
evacuation of acrimony, such, for instance, as mercury, 
may be employed. f 

289.] In the Ophthalmia tarsi, it almost constantly hap- 
pens that some ulcerations are formed on the tarsus. These 
require the application of mercury or copper, either of 
■which may by itself sometimes entirely cure the affection ; 
and these may even be useful when the disease depends upon 
a fault of the whole system. 

290.] Both in the Ophthalmia membranarum, and in the 
Ophthalmia tarsi, it is necessary to obviate that gluing or 
sticking together of the eye-lids which commonly happens 
m sleep ; and this may be done by insinuating a little of 
any mild unctious medicine, of some tenacity between the 
eye-lids before the patient shall go to sleep 4 

* A solution of a scruple of sugar of lead in four ounces of distilled water, is a very effectual 
application j some authors recommend equal parts of white vitiol and sugar of lead dissolved in 
distilled water. These collyria, as they are called, do infinite mischief if they aie too strong. 

If, therefore, the patient complains of the least smarting on their application, it will be neces- 
sary to dilute them with the addition of more distilled water. '] hey ought to he applied cold, 
and pledgets moistened with them ought to he frequent!) renewed when they grow hot or dry. 
An additional direction may be added, viz. thai the solution of saccharum saiurni be always 
made ;n distilled water, especialh when it is to be used as a coll) num, because the least in.; 
nat on of any mineral acid, however combined, decomposes the sugar of lead. 

Cold poultices of rasped raw potatoes or turnips are sometimes very efficacious. They may 
be applied in a tine muslin bag, and ought to be renewed whenever they grow warm. 

+ It the ophthalmia be venereal, mercury is the only remedy, and external applications have 
little effect. If scrophula is the cause, relief is often speedily procured by an application of the 
Coagulum a luminis, or the unguentum citrinum, now called unguentum hydrargyri nitralurp 
in the London Pharmacopoeia. The unguentum tutia.' has been used in many cases with ads an- 
tage, as has also the unguentum cerussx aeetata.'. but these topical applications never eflecl4 
permanent cure. 

t Hog's lard, fresh pressed lintseed-oil, or oil of almonds, answer this intention very well, 0! 
the unguentum spermatis ceti, oUhe London Pharmaeopa-ia. 



PRACTICE OF PHYSIC. 113 

CHAPTER IV. 
OF PHRENZV, OR PHRENITIS. 

291.] r THHIS disease is an inflammation of the parts 
X contained in the cavity of the cranium ; and 
may affect cither the membranes or the brain, or the sub- 
stance of the brain itself. Nosologists have apprehended, 
that these two cases might be distinguished by different 
symptoms, and therefore by different appellations: but 
this tloes not seem to be confirmed by observation and dis- 
section ; and therefore I shall treat of both cases under the 
title of Phrenzy, or Phrenitis. 

292.] An idiopathic phrenzy is a rare occurrence, a 
sympathic more frequent ; and the ascertaining either the 
one or the other is, upon many occasions, difficult. Many 
of the symptoms by which the disease is most commonly 
judged to be present, have appeared, when from certain 
considerations, it was presumed, and even from dissection 
it appeared, that there had been no internal inflammation ; 
and on the other hand, dissections have shown, that the 
brain had been inflamed, when few or' the peculiar symp- 
toms of phrenzy had before appeared.* 

293.] The symptoms by which this disease may be most 
certainly known, are a vehement pyrexia, or a violent deep- 
seated headach, a redness and turgescence of the face and 
eyes, an impatience of light and noise, a constant watch- 
ing and a delirium impetuous and furious. Some nosolo- 
gists have thought these symptoms peculiar to an inflam- 
mation of the membranes, and that the inflammation of 
the substance of the brain was to be distinguished by some 
degree of coma attending it. It was for this reason that 
in the Nosology I added the Typhomania to the character 
of Phrenitis ; but upon further reflection, I find no proper 
foundation for this; and if Ave pass from the characters 
above delivered, there will be no means of fixing the va- 
riety that occurs. 

I am here, as in other analogous cases, of opinion, that 
the symptoms above mentioned of an acute inflammation, 
always mark inflammations of membranous parts; and that 

* This sentence is very obscure ; the Author meant to sav, that the diagnostic sjmptorrs of 
tfris disease are uncertain. 



114 PRACTICE OF PHYSIC. 

an inflammation of the paronchyma or substance of visce- 
ra, exhibits, at least commonly, a more chronic affection. 

294.] The remote causes of phrenzy, are all those which 
directly stimulate the membranes or substance of the brain ; 
and particularly all those which increase the impetus of the 
blood in the vessels of the brain. Among these the expo- 
sure of the naked head to the direct rays of a very warm 
sun, is a frequent cause. The passions of the mind, and 
certain poisons, are amongst the remote causes of phrenzy ; 
but in what manner thev operate is not well understood.* 

295.] The cure of phrenzy is the same with that of in- 
flammation in general ; but in phrenzy the most powerful 
remedies are to be immediately employed. Large and re- 
peated blood-letting is especially necessary ; and the blood 
should be drawn from vessels as near as possible to the part 
affected. The opening of the temporal artery has been re- 
commended, and with some reason : but the practice is at- 
tended with inconvenience ; and I apprehend that opening 
the jugular veins may prove more effectual ; but at the same 
time, it will be generally proper to draw blood from the 
temples by cupping and scarifying. 

296.] It is probable, that purging, as it may operate by 
revulsion, may be of more use in this than in some other in- 
flammatory affections. 

For the same purpose of revulsion, warm pediluvia are 
a remedy ; but at the same time somewhat ambiguous. The 
taking off the force of the blood in the vessels or the head by 
an erect posture, is generally useful. 

297.] Shaving of the head is always proper and necessary 
for the admission of other remedies. Blistering is commonly 

* Practitioners liave in general admitted two kinds of phrenzy, viz. the idiopathic or true 
phrenzy, and the symptomatic. The former is what the author describes in the text; and, as 
he has omitted to describe the latter, which in article 292, he acknowledges to be the more 
frequent oi the two, I shall enumerate its symptoms. 

The symptomatic phrenzy is constantly preceded by some very acute inflammatory fever. Its 
approach may be suspected by a suppression of the excretions, by colorless stools, by a black 
dry, and rough tongue, by pale and watery urine, which sometimes has black or dark brown 
clouds floating in it. by a desire but inability to sleep, by picking the bed clothes, by the eyes 
appearing fierce, and the vessels of the albuginca becoming turgid, and by a lew drops' of blood 
oistilling from the nose. 

When most of these symptoms appear in inflammatory fevers, we justly apprehend an attack 
»f the phrenzy, and ought to have immediate recourse to such remedies as will lessen its violence, 
or altogether prevent its access. Large bleedings, if the pulse permits, must be made on the 
lower extremities, emollient glysters are to be frequently injected, laxatives administered, fo- 
mentations applied to the feet and legs, cupping glasses applied on the thighs, and the patient must 
he forced to drink plentifully, for he is seldom thirsty in these cases, although his tongue be 
parched. Besides these general remedies, peculiar attention must be paid to the primary disease; 
and the treatment of the symptomatic phrenzy will vary according to the nature of the disease 
bv which it is produced. 

No part of the practice of physic requires more judgment and segacity in the practitioner, 
than ascertaining the proper mode of treating the symptomatic phrenzy in different fevers. To 
enter fully into the subject, would require more room than these notes allow. 1 can only there- 
fore recommend the young practitioner to pay great attention to it. He will find many useful 
practical directions lor the treatment of these cases, in most of the medical writers, both ancient 
ind modern, especully Sydenham and Van Sweiten. 



PRACTICE OF PHYSIC. us 

useful in this disease, but chiefly when applied near the part 
affected.* 

298.] Every part of the antiphlogistic regimen is here 
necessary, and particularly the admission of cold air. Even 
cold substances, applied close to the head, have been found 
safe and highly useful ; and the application of such refrige- 
rants as vinegar, is certainly proper. f 

299.] It appears tome certain, that opiates are hurtful 
in every inflammatory state of the brain ; and it is to be 
observed, that, from the ambiguity mentioned in (292.) 
the accounts of practitioners, with regard to the juvantia 
and hedentia in this disease, are of very uncertain applica- 
tion. 



CHAPTER V. 

OF THE QUINSYy OR CYNANCIIE. 

300.] r T^HIS name is applied to every inflammation of 
JL the internal fauces ; but these inflammations 
are different, according to the part of the fauces which may 
be affected, and according to the nature of the inflammation. 
In the Nosology, therefore, after giving the character of the 
Cynanche as a genus, I have distinguished five different 
species, which must here likewise be separately considered. 



SECTION I. 

Of the Cynanche Tonsillaris. 

301.] THIS is an inflammation of the mucous membrane 
of the fauces, affecting especially that congeries of mucou9 
follicles which forms the tonsils, and spreading from thence 
along the velum and uvula, so as frequently to affect every 
part of the mucous membrane. 

* It has been usual to apply a large blistering plaister over the whole head, and suffer it to 
remain on for eight and forty hours. This, however, hinders the application of other very 
powerful remedies. Shaving the head of a frantic patient is always a troublesome operation ; 
but ihc very gTcat benefit arising from it, renders it absolutely necessary in all cases; and the 
physician wught therefore to advise it on the first liupicion oi an approaching phrenzy. 

+ Many eminent practitioners have dissuaded the use of these refrigerant applications to the 
newly shaven head ; the immediate relief which the mere shaving generally procures seems to 
indicate the propriety of the practice and experience has not discovered any material dii»d-- 
■Midiiij: i', bui en the coutwry, much benefit accruing frvm it. 



116 PRACTICE OF PHYSIC. 

302.] The disease appears by some tumor, sometimes 
considerable, and by a redness of the parts ; is attended with 
a painful and difficult deglutition; with. a pain sometimes 
shooting into the ear ; with a troublesome clamminess of the 
mouth and throat ; with a frequent, but difficult, excretion of 
mucous; and the whole is accompanied with a pyrexia. 

303.] This species of quinsy is never contagious. It 
terminates frequently by resolution,* sometimes by suppu- 
ration, but hardly ever' by gangrene; although in this dis- 
ease some sloughy spots commonly supposed to be forerun- 
ners of gangrene, sometimes appear upon the fauces. 

304.] This disease is commonly occasioned by cold ex- 
ternally applied, particularly about the neck. It affects 
especially the young and sanguine, and a disposition to it is 
often acquired by habit ; so that from every considerable 
application of cold to any part of the body, this disease is 
readily induced. It occurs especially in spring and autumn, 
when vicissitudes of heat and cold frequently take place. 
The inflammation and tumor are commonly at first most 
considerable in one tonsil; and afterwards abating in that, 
increase in the other. 

305.] In the cure of this inflammation, some bleeding may 
be proper : but large general bleedings will seldom be ne- 
cessary. The opening of the rantilar veins seems to be an 
insignificant remedy ; and leeches set upon the external 
fauces are of more efficacy. 

306.] At the beginning of the disease,- full vomiting has 
been frequently found to be of great service. f 

307. J This inflammation may be often relieved by mode- 
rate astringents, and particularly by acids applied to the 
inflamed pafts.J In many cases, however, nothing has been 
found to give more relief than the vapor of warm water 
received into the fauces by a proper apparatus. 

308.] The other remedies of this disease are rubefacient 
or blistering medicines, applied externally to the neck ; and 
with these, the employment of antiphlogistic purgatives,^ 

* As the most frequent termination of this disease is bv resolution, this mode of cure rnu»'. 
»lwavs he attempted, and w ill seldom fail of proving successful. 

+ The formula of an emetic may be seen in the note on art. 18:5. 

t Various have been the opinions ot physician, respecting the kind of gargles proper in these 
cases, a pint of tincture of roses, with 'two drachms of honey, lias often been found sen 
able. The following [uentty used with success. Boil an ounce of oak-b.uk, bi ; 

in a quart of water, tal half is evaporated, and to the strained liquor add an ounce ot honey of 
roses, and a drachm ol aiium. Sa^e tea, « ith honey, is in common use, and frequently answer: 
every purpose. 

i Glauber's Salts answer the end of purges in these cases very well, especially if the patient 
drinks copiously during the .operation. 



PRACTICE OF PHYSIC. m 

as well as every part of the antiphlogistic regimen, except- 
ing the application of cold. 

309.] This disease, as we have said, often terminates by 
resolution, frequently accompanied with sweating ; which is 
therefore to be prudently favored and encouraged.* 

310.] When this disease shall have taken a tendency to 
suppuration, nothing will be more useful, than the frequent 
taking into the fauces the steams of warm water.f When 
the abscess is attended with much swelling, if it break not 
spontaneously, it should be opened by a lancet ; and this 
does not require much caution, as even the inflammatory 
state may be relieved by some scarification of the tonsils. 

I have never had occasion to see any case requiring 
bronchotomy. 



SECTION II. 

Of the Cynanche Maligna, 



311.] THIS is a contagious disease, seldom sporadic, and 
commonly epidemic. It attacks persons of all ages but 
more commonly those in a young and infant state. It at- 
tacks persons of every constitution when exposed to the con- 
tagion, but most readily the weak and infirm. 

312.] This disease is usually attended with a considera- 
ble pyrexia; and the symptoms of the accession of this, such 
as frequent cold shiverings, sickness, anxiety, and vomit- 

* Dover's powder is an excellent sudorific in these cases. The method of giving it has been 
described in a former note, in art. 169. Many other sudorifics, however, are found to answer 
tolerably well, as wine-whey, whey made with dulcified spirit of nitre, vinegar-whey, sage tea, 
with several other drinks of a similar kind. The following bolus is often very efficacious, espe- 
cially when the patient drinks largely of sage or balm tej. 

ft. Camphor, gr. viii. 
Opii pur. gr. i. 
Tart. Vitriolat. 9i. 
Tere in mortario marmoreo ; et adde 
Confect. cardiac. 5i. vel. q. s. ut flat bolus. 

Small doses of tartar emetic taken in such quantities as to produce a slight nausea without 
vomiting, are also good sudorifics. Two table-spoonfuls of the following julep may be taken 
every haif hour, till the effect be produced, drinking, at the same time, plentifully of some warm 
diluent. 

R. Tartar, emetic, gr. iii. 
Aq. font. Bvii. 
Syr. Papaveris rubri, |i. 
M. f. julap. 

+ Very convenient apparatus for this purpose are made by most tin-workers. Beside the steam 
of w.irni water here recommended, external applications to the throat and sides of the neck 
k*ve a considerable effect in forwarding the suppuration, as warm poultices, fomentations, fce, 

Q 



118 PRACTICE OF PHYSIC. 

ing, are often the first appearances of the disease^ About 
the same time, a stiffness is felt in the neck, with some un- 
easiness in the internal fauces, and some hoarseness of the 
voice. The internal fauces, when viewed appear of a deep 
red color, with some tumor; but this last is seldom con- 
siderable, and deglutition is seldom difficult or painful. Ve- 
ry soon a number of white or ash colored spots appear 
upon the inflamed parts. These spots spread and unite, 
covering almost the whole fauces with thick sloughs ; which 
falling off, discover ulcerations. While these symptoms 
proceed in the fauces, they are generally attended with a 
coryza which pours out a thin acrid and fetid matter, exco- 
riating the nostrils and lips. There is often also, especially 
in infants, a frequent purging; and a thin acrid matter 
flows from the anus excoriating this and the neighboring 
parts. 

313.] With these symptoms, the pyrexia proceeds with 
a small, frequent, and irregular pulse; and there occurs a 
manifest exacerbation every evening, and some remission 
in the mornings. A great debility appears in the animal 
functions ; and the sensorium is affected with delirium, 
frequently with coma. 

314.] On the second day, or sometimes later, efflores- 
cences appear upon the skin, which are sometimes in small 
points hardly eminent ; but, for the most part, in patches 
of a red color, spreading and uniting so as to cover the whole 
skin. They appear first about the face and neck, and in 
the course of some days spread by degrees to the lower ex- 
tremities. The scarlet redness is often considerable on the 
hands and extremities of the fingers, which feel stiff and 
swelled. This eruption is often irregular, as to the time 
of its appearance, as to its steadiness, and as to the time 
of its duration. It usually continues four days, and goes 
off by some desquamation of the cuticle ; but neither on 
its first appearance, nor on its desquamation, does it always 
produce a remission of the pyrexia, or of the other symp- 
toms. 

315.] The progress of the disease depends on the state 
of the fauces and of the pyrexia. When the ulcers on the 
fauces, by their livid and black color, by the fetor of the 
breath, and by many marks of acrimony in the fluids, show 
a tendency to gangrene, this takes place to a considerable 
degree; and the symptoms of a putrid fever constantly in- 
creasing, the patient dies, often on the third day, some- 



PRACTICE OF PHYSIC. U9 

times later, but for the most part before the seventh. The 
acrimony poured out from the diseased fauces must neces- 
sarily, in part, pass into the pharynx, and there spread 
the infection into the oesophagus, and sometimes through 
the whole of the alimentary canal, propagating the pu- 
trefaction, and often exhausting the patient by a frequent 
diarrhoea. 

The acrid matter poured out in the fauces being again 
absorbed, frequently occasions large swellings of the lym- 
phatic glands about the neck, and sometimes to such a 
degree as to occasion suffocation. 

It is seldom that the organs of respiration escape entire- 
ly unhurt, and very often the inflammatory affection is com- 
municated to them. From dissections it appears, that, in 
the Cynanche maligna, the larynx and trachea are often af- 
fected in the same manner as in the Cynanche trachealis ; 
and it is probable, that, in consequence of that affection, 
the Cynanche maligna often proves fatal by such a sudden 
suffocation as happens in the proper Cynanche trachealis ; 
but there is reason to suspect, that upon this subject dissec- 
tors have not always distinguished properly between the 
two diseases. 

316.] These are the several fatal terminations of the Cy- 
nanche maligna ; but they do not always take place. Some- 
times the ulcers of the fauces are of a milder nature ; and 
the fever is more moderate, as well as of a less putrid kind. 
And when, upon the appearance of the efflorescence on the 
skin, the fever suffers a remission ; when the efflorescence 
continues for three or four days, till it has spread over the 
whole body, and then ends by a desquamation, giving a 
further remission of the fever ; this often entirely termi- 
nates, by gentle sweats, on or before the seventh day ; and 
the rest of the disease terminates in a few days more, bv an 
excretion of sloughs from the fauces; while sleep, appetite, 
and the other marks of health return. 

From what is said in this and the preceding paragraph, 
the prognostics in this disease may be readily learned. 

317.] In the cure of this disease, its septic tendency is 
chiefly to be kept in view. The debility, with which it is 
attended, renders all evacuations by bleeding and purging 
improper, except in a few instances where the debility is 
less, and the inflammatory symptoms more considerable. 
The fauces are to be preserved from the effects of the acrid 
matter poured out upon them, and arc therefore to be fre- 



120 PRACTICE OF PHYSIC. 

quently washed out by antiseptic gargles* or injections ; 
and the septic tendency of the whole system should be 
guarded against and corrected by internal antiseptics, espe- 
cial^ by the Peruvian bark given in substance, from the 
beginning, and continued through the course of the disease, f 
Emetics, 'both by vomiting and nauseating, prove useful, 
especially when employed early in the disease. When any 
considerable tumor occurs, blisters applied externally will 
be of service, and in any case may be fit to moderate the 
internal inflammation.^ 

* When the violence of the symptoms is moderate, and when the ulceration is slight, sage tea, 
or tea made of rose leaves, or both together, may be sufficient. A gargle made of a pint of 
sage and rose tea, three spoonfuls of vinegar, and one spoonful of honey, has been found as 
efficacious as any of the sharper antiseptics with the mineral acids. Dr. Fothergill's gargle is, 

R. Decoct, pectoral. Sxii. cui inter coquendum adde 
Rad. contrayerv. contus. Bss. 
Liquori colato admisce, 
Acet. vin. alb. 3ii. 
Tict. myrrh. §i. 
Mel. opt. 3vi. 

But he often used it with a drachm of the Mel Egyptiacum dissolved in two ounces of it. 

The Mel Egyptiacum is a very harsh application, and ought to be cautiously used. If the 
sloughs cast oil so slowly as to require a powerful application, it is better practice to touch them 
with Mel Egyptiacum by means of an armed probe, than to use gargles in which it is an ingredi- 
ent. In this disease, a strict attention must be given to the use of gargles and injections for the 
throat, because the cure seems to depend in part on procuring a discharge from the glands of 
the fauces which these gargles induce, and also because they are the only means of retarding 
the progress of the ulcers. 

+ The quantity of bark given ought to be very considerable, viz. as much as the stomach and 
intestines can possibly bear ; half a drachm or two scruples every hour, with a glass of good 
Port wine. A scruple of confectiocardiaca, joined with each dose of the bark, has a double ef- 
fect of making the bark less nauseous, and of preventing in some measure, a tendency to a diar- 
rhoea, but opium is a sovereign remedy for removing this symptom when it is actually present. 

In administering the bark, great care must be taken to avoid a diarrhoea, which is a very dan- 
gerous symptom in any period of the disease, but especially after the third or fourth day, when 
the patient is in a considerable state of debility. 

Children are more frequently attacked with this disease than adults ; and it is sometimes ex- 
tremely difficult to prevail on them to take a sufficient quantity of this necessary and valuable, 
though nauseous medicine. In these cases glyslcrs with powdered bark have been used with 
very great success. Two drachms of the fine powder may be given in five or six ounces of bar- 
ley-water, every 3 or 4 hours to very young children, and half an ounce or 6 drachms to chil- 
dren of 8 or 10 years old, in three quarters of a pint of barley-water. If the first glyster comes 
away too speedily, two or three grains of opium may be added to the subsequent gtysters. 

i In addition to the method of cure here delivered, it may be proper to observe, that as the 
cure depends much on the removal of every thing putrid from the patient, it is absolutely ne- 
cessary to have the room well ventilated, but not with cold air. The reason for this precaution 
is, that the patient always complains of the least admission of cold air, becoming sick and op- 
pressed, probably in consequence of the sudden disappearance of the efflorescence which al- 
ways accompanies the disease. The linen ought frequently to be changed, the patient kept 
clean, the mouth and throat frequently washed, and great plenty of liquid vegetable nutriment 
must be given, with generous wine. 

A hemorrage from the nobt, mouth, or ears, very frequently occurs in the later stages of a. 
malignant soie throat. This discharge is by no means ci itical, but always a dangerous symptom, 
and must be stopped with the utmost expedition. It is the consequence of some arterial 
branch being corroded by the mortification. If the hemorrhage withstands the usual means of 
tents dipped in vinegar, or a solution of alum, &c. recour ; e must be had to opium and bark ; 
and the Port wine must be given sparingly. 

In the advanced stages, a diarrhoea frequently appears, especially in children; it proceeds 
from the putrid and acrid matter of the ulcers being received in to the intestines. It can only be 
prevented, or effectually removed, by a careful attention to keep the mouth as clean as possible. 



PRACTICE OF PHYSIC. 121 



SECTION III. 
Of the Cynanche Trachealis. 

318.] THIS* name has been given to an inflammation of 
the glottis, larynx, or upper part of the trachea whether it 
affect the membranes of these parts, or the muscles adjoin- 
ing. It may arise first in these parts, and continue to sub- 
sist in them alone ; or it may come to affect these parts from 
the Cynanche tonsillaris or maligna spreading into them. 

319.] In either way it has been a rare occurrence, and 
few instances of it have been marked and recorded by phy- 
sicians. It is to be known by a peculiar ringing sound of 
the voice, by difficult respiration, with a sense of straitening 
about the larynx, and by a pyrexia attending it. 

320.] From the nature of these symptoms, and from the 
dissection of the bodies of persons who had died of this dis- 
ease, there is no doubt of its being of an inflammatory 
nature. It does not, however, always run the course of in- 
flammatory affections, but frequently produces such an ob- 
struction of the passage of the air, as suffocates, and thereby 
proves suddenly fatal. 

321.] If we judge rightly of the nature of this disease, it 
will be obvious, that the cure of it requires the most power- 
ful remedies of inflammation, to be employed upon the very 
first appearance of the symptoms. VVhen a suffocation is 
threatened, whether any remedies can be employed to pre- 
vent it, we have not had expei'ience to determine. 

322.] The accounts which books have hitherto given us 
of inflammations of the larynx, and the parts connected with 
it, amount to what we have now said ; and the instances re- 
corded have almost all of them happened in adult persons ; 
but there is a peculiar affection of this kind happening espe- 
cially to infants, which till lately has been little taken notice 
of. Dr. Home is the first who has given any distinct account 
of it ; but, since he wrote, several other authors have taken 
notice of it, (see Michaelis De angina poly posa sive mem- 
hrancia, slrgentorati 1778) and have given different opi- 
nions with regard to it. Concerning this diversity of 

* Tins disease ha? been supposed to be new. and confined chiefly to infants. It is, however. 

. 'iiyuf both the undent and modern writers. Boernaaye describes it in his 601si 

•I i-,m. It ii, indeed, uncommon in adults, and most frequent in infants. It was 

od, however, till Dr. Home, the Profenor of the Materia Medica in this 

led its nature, and pointed out the only effectual metru d of cure. 



122 practice of Physic. 

opinions I shall not at present inquire ; but shall deliver the 
history and cure of this disease, in so far as these have arisen 
from my own observation, from that of Dr. Home, and of 
other skilful persons in this neighborhood. 

323.] This disease seldom attacks infants till after they 
have been weaned. After this period, the younger they 
are, the more they are liable to it. The frequency of it 
becomes less as children become more advanced ; and there 
are no instances of children above twelve years of age being 
affected with it. It attacks children of the midland coun- 
tries, as well as those who live near the sea. It does net 
appear to be contagious, and its attacks are frequently re- 
peated in the same child. It is often manifestly the effect 
of cold applied to the body ; and therefore appears most 
frequently in the winter and spring seasons. It very com- 
monly comes on with the ordinary symptoms of a catarrh ; 
but sometimes the peculiar symptoms of the disease show 
themselves at the very first. 

324.] These peculiar symptoms are the following : A 
hoarseness, with some shrillness and ringing sound, both in 
speaking and coughing, as if the noise came from a bra- 
zen tube. At the same time, there is a sense of pain about 
the larynx, some difficulty of respiration, with a whizzing 
sound in inspiration, as if the passage of the air were strait- 
ened. The cough which attends it, is commonly dry ; and if 
any thing be spit up, it is a matter of a purulent appearance, 
and sometimes films resembling portions of a membrane. 
Together with these symptoms, there is a frequency of pulse, 
a restlessness, and an uneasy sense of heat. 

When the internal fauces are viewed, they are sometimes 
without any appearance of inflammation : but frequently a 
redness and even swelling, appear ; and sometimes in the 
fauces there is an appearance of matter like to that rejected 
by coughing. With the symptoms now described and par- 
ticularly with great difficulty of breathing, and a sense of 
strangling in the fauces, the patient is sometimes suddenly 
taken off". 

325.] There have been many dissections made of infants 
who had died of this disease ; and almost constantly there 
has appeared a preternatural membrane lining the whole in- 
ternal surface of the upper part of the trachea, and ex- 
tending in the same manner downwards into some ci its 
ramifications. This preternatural membrane may be easily 
separated, and sometimes has been found separated in part, 



PRACTICE OF PHYSIC. 123 

from the subjacent proper membrane of the trachea. This 
last is commonly found entire, that is, without any appear- 
ance of erosion or ulceration ; but it frequently shows the 
vestiges of inflammation, and is covered by a matter resem- 
bling pus, like to that rejected by coughing ; and very often 
a matter of the same kind is found in the bronchiae, some- 
times in considerable quantity. 

326.] From the remote causes of this disease ; from the 
catarrhal symptoms commonly attending it ; from the py- 
rexia constantly present with it ; from the same kind of 
prete rnatural membrane being found in the trachea when 
the cynanche maligna is communicated to it ; and, from 
the vestiges of inflammation on the trachea discovered up- 
on dissection ; we must conclude, that the disease consists 
in an inflammatory affection of the mucous membrane of 
the larynx and trachea, producing an exudation analogous 
to that found on the surface of inflamed viscera, and ap- 
pearing partly in a membranous crust, and partly in a 
fluid resembling pus. 

327.] Though this disease manifestly consists in an in- 
flammatory affection, it does not commonly end either in 
suppuration or gangrene. The peculiar and troublesome 
circumstance of the disease seems to consist in a spasm of 
the muscles of the glottis, which by inducing a suffocation, 
prevents the common consequences of inflammation. 

323.] When this disease terminates in health, it is by a 
resolution of the inflammation, by a ceasing of the spasm of 
the glottis, by an expectoration of the matter exuding from 
the trachea, and of the crusts formed there ; and frequent- 
ly it ends without any expectoration, or at least with such 
only as attends an ordinary catarrh. 

329.] When the disease ends fatally, it is by a suffoca- 
tion ; seemingly, as we have said, depending upon a spasm 
affecting the glottis ; but sometimes, probably, depending 
upon a quantity of matter filling the bronchiae. 

330.] As we suppose the disease to be an inflammatory 
affection, so we attempt the cure of it by the usual remedies 
of inflammation, and which for the most part I have found 
effectual. Bleeding, both general and topical,* has often 

* The topical bleeding is best performed by leeches. Three or four may be applied at once 
en each tide of the trachea, or on the trachea itseif. Notwithstanding this recommendation "' 
topical bleeding, previous general bleeding is absolutely necessary in every case, and ought ne- 
ver to be omitted. It frequently produces relict even while the blood is flowing from the vein; 
but, in these cases, it is impi udent to stop the evacuation, even on the total removal ot the s\ mp- 
toins. As much blood must be drawn as the infant can bear to h »e, and leeches oup 1 
ver to be applied, as above directed ; for it frequently happens, that, when all the symptoms sud- 
denly disappear, the disease returns in a f ew U^ts with redoubled viu.- rce. . i 
an end to the child's life. 



124 PRACTICE OF PHYSIC. 

given immediate relief; and by being repeated, has en- 
tirely cured the disease. Blistering also, near to the part 
affected, has been found useful. Upon the first attack of 
the disease, vomiting, immediately after bleeding, seems to 
be of considerable use, and sometimes suddenly removes 
the disease. In every stage of the disease, the antiphlo- 
gistic regimen is necessary, and particularly the frequent 
use of laxative glysters.* Though we suppose that a 
spasm affecting the glottis is often fatal in this disease, I 
have not found antispasmodic medicines to be of any use. 



SECTION IV. 

Of the Cynanche Pharyngaa. 

331.] IN the Cynanche tonsillaris, the inflammation of 
the mucous membrane often spreads upon the pharynx, and 
into the beginning of the oesophagus, and thereby renders 
deglutition more difficult and uneasy ; but such a case does 
not require to be distinguished as a different species, from 
the common Cynanche tonsillaris ; and only requires that 
bloodletting, and other remedies, should be employed with 
greater diligence than in ordinary cases. We have never 
seen any case, in which the inflammation began in the 
pharynx, or in which this part alone was inflamed ; but 
praetical writers have taken notice of such a case ; and to 
them, therefore, I must refer, both for the appearances 
which distinguish it, and for the method of cure. 



SECTION V. 

Of the Cynanche Parotidaa. 

332.] THIS is a disease known to the vulgar, and among 
them has got a peculiar appellation, in every country of 
Europe ;f but has been little taken notice of by medical 
writers. It is often epidemic, and manifestly contagious. 

* Laxative glysters are to be carefully distinguished from purging glysters, which generally 
irritate too violently, and thus increase the inflammatory diathesis. U is of little consequence 
what the compositions of glysters be, provided they contain some Glauber's or Epsom salt, and 
are sufficiently large. The common glysierwiih milk and water, and a little Epsora salt, an- 
swers sufficiently well, 

+ It is called here, and in many parts of Great-Eri tain, The Mum}:. 



PRACTICE OF PHYSIC. i 2 £ 

It comes on with the usual symptoms of pyrexia, which is 
soon after attended with a considerable tumor of the exter- 
nal fauces and neck. — This tumor appears first as a glandu- 
Jar moveable tumor at the corner of the lower jaw ; but the 
swelling soon becomes uniformly diffused over a great part 
of the neck, sometimes on one side only, but more common- 
ly on both. The swelling continues to increase till the fourth 
day ; but from that period it declines, and in a few days more 
passes off entirely. As the swelling of the fauces recedes, 
some tumor affects the testicles in the male sex, or the breasts 
in the female. These tumors are sometimes large, hard, and 
somewhat painful ; but in this climate are seldom either ve- 
ry painful or of long continuance. The pyrexia attending 
this disease is commonly slight, and recedes with the swell- 
ing of the fauces ; but sometimes, when the swelling of the 
testicles does not succeed to that of the fauces, or when the 
one or the other has been suddenly repressed, the pyrexia, 
becomes more considerable, is often attended with delirium, 
and has sometimes proved fatal. 

333.] As this disease commonly runs its course without 
either dangerous or troublesome symptoms, so it hardly re- 
quires any remedies. An antiphlogistic regimen and avoid- 
ing cold, are all that will be commonly necessary. But 
when, upon the receding of the swellings of the testicles in, 
males, or of the breasts in females, the pyrexia comes to be 
considerable, and threatens an affection of the brain, it will 
be proper, by warm fomentations, to bring back the swell- 
ing ; and by vomiting, bleeding, or blistering, to obviate 
the consequences of its absence. 



CHAPTER VI. 



OF PNEUMONIA, OR PNEUMONIC INFLAM- 
MATION. 

334.] " ' TNDER this title I mean to comprehend the 
KJ whole of the inflammations affecting either 
the viscera of the thorax, or the membrane lining the inte- 
rior surface of that cavity : for neither do our diagnostics 
serve to ascertain exactly the seat of the disease ; nor does 
the difference in the seat of the disease exhibit any consider- 
able variation in the state of the symptoms, nor lead to any 
difference in the method of cure. 



126 PRACTICE OF PHYSIC. 

335.] Pneumonic inflammation, however various in its 
seat, seems to me to be always known and distinguished by 
the following svmptoms : pyrexia, difficult breathing, cough 
and pain in some parts of the thorax. But these symptoms 
are, on different occasions, variously modified. 

336.] The disease almost always comes on with a cold 
stage, and is accompanied with the other symptoms of py- 
rexia ; though, in a few instances, the pulse may not be more 
frequent, nor the heat of the body increased beyond what is 
natural. Sometimes the pyrexia is from the beginning ac- 
companied with the other symptoms ; but frequently it is 
formed for some hours before the other symptoms become 
considerable, and particularly before the pain be felt. For 
the most part, the pulse is frequent,* full, strong, hard, and 
quick ;f but in a few instances, especially in the advanced 
state of the disease, the pulse is weak and soft, and at the 
same time irregular. 

337.] The difficulty of breathing is always present, and 
most considerable in inspiration; both because the lungs do 
not easily admit of a full dilatation, and because the dilata- 
tion aggravates the pain attending the disease. The diffi- 
culty of breathing is also greater, when the patient is in one 
posture of his body rather than another. It is generally 
greater when he lies upon the side affected ; but sometimes 
the contrary happens. Very often the patient cannot lie 
easy upon either side, finding ease only when lying on his 
back ; and sometimes he cannot breathe easily, except when 
in somewhat of an erect posture. 

338.] A cough always attends this disease ; but in differ- 
ent cases, is more or less urgent and painful. It is some- 
times dry, that is, without any expectoration, especially in 
the beginning of the disease ; but more commonly it is, even 
from the first, moist, and the matter spit up various both 
in consistence and color; and frequently it is streaked with 
blood.J 

339.] The pain attending this disease, is in different ca- 
ses, felt in different parts of the thorax, but most frequent- 
ly in one side. It has been said to affect the right side 

* A frequent pul-e ii when there is a great ncmber of strokes in a given time. 

+ A quick pulse is when the stroke itself is quick, although tie number in a given time be not 
very great. 

It is therefore to mention both frequent and quick, as they are really distinct, 

and may be both present at once ; but, if the pulse be aijove an hundred in a minute, the phy- 
sician mu;t ha\ e a very nice sense of feeling to distinguish between a quick and a slow beat. 

% Young practitioners should not be alarmed at this symptom : nor should they suppose it a 
dangerousone: it i;, onthe contrary, a salutary symptom, and ought nut to be restrained, 
either by too rigorous an adherence to the antiphlogistic regimen, or by the use of styptics and 
vther astringents . 



PRACTICE OF PHYSIC. 13.7 

more frequently than the left ; but this is not certain ; while 
on the other hand, it is certain that the left side has been 
very often affected. The pain is felt sometimes as if it were 
under the sternum; sometimes in the back between the 
shoulders; and when in the sides, its place has been higher 
or lower, more forward or backward: but the place of all 
others most frequently affected, is about the sixth or se- 
venth rib, near the middle of its length, or a little more 
forward. The pain is often severe and pungent ; but some- 
times more dull and obtuse, with a sense of weight rather 
than of pain. It is most especially severe and pungent 
when occupying the place last mentioned. For the most 
part it continues fixed in one place ; but sometimes shoots 
from the side to the scapula on one hand, or to the ster- 
num and clavicle on the other. 

340.] The varying state of symptoms now mentioned, 
does not always ascertain precisely the seat of the disease. 
To me it seems probable, that the disease is always seated, 
or at least begins, in some part of the pleura; taking that 
membrane in is greatest extent, as now commonly under- 
stood ; that is, as covering not only the internal surface of 
the cavity of the thorax, but also as forming the mediasti- 
num, and as extended over the pericardium, and over the 
whole surface of the lungs. 

341.] There is, therefore, little foundation for distin- 
guishing this disease by different appellations taken from 
the part which may be supposed to be chiefly affected. 
The term Pleurisy, might with propriety be applied to ev- 
ery case of the disease; and has been very improperly li- 
mited to that inflammation which begins in, and chiefly af- 
fects the pleura costalis. I have no doubt that such a case 
does truly occur; but, at the same time, I apprehend it to 
be a rare occurrence ; and that the disease much more fre- 
quently begins in, and chiefly affects, the pleura invest- 
ing the lungs, producing all the symptoms supposed to 
belong to what has been called the Pleuritis •vera. 

34U.J Some physicians have imagined, that there is a case 
of pneumonic inflammation particularly entitled to the 
appellation of Peripneumony ; and that is, the case of an 
inflammation beginning in the parenchyma or cellular tex- 
ture of the lungs, and having its seat "chiefly there. But 
■us to me very doubtful, if any acute inflammation 
of the lungs or any disease which has been called Perip- 
neumony be of that kind. It seems probable, that every 



123 PRACTICE OF PHYSIC. 

acute inflammation begins in membranous parts ; and, in 
every dissection of persons dead of peripneumony, the ex- 
ternal membrane of the lungs, or some part of the pleura, 
has appeared to have been considerably affected. 

343.] An inflammation of the pleura covering the upper 
surface of the diaphragm, has been distinguished by the 
appellation of Paraphrenias, as supposed to be attended 
■with the peculiar symptoms of delirium, risus sardonicus, 
and other convulsive motions : but it is certain, that an in- 
flammation of that portion of the pleura, and affecting also 
even the muscular substance of the diaphragm, has often 
taken place without any of these symptoms ; and I have not 
met with either dissections, or any accounts of dissections, 
which support the opinion, than an inflammation of the 
pleura covering the diaphragm, is attended with delirium 
more commonly than any other pneumonic inflammation. 

344.] With respect to the seat of pneumonic inflamma- 
tion, I must observe further, that although it may arise 
and subsist chiefly in one part of the pleura only, it is how- 
ever frequently communicated to other parts of the same, 
and commonly communicates a morbid affection through 
its whole extent. 

345.] The remote cause of pneumonic inflammation, is 
commonly cold applied to the body, obstructing perspira- 
tion, and determining to the lungs ; while at the same time 
the lungs themselves are exposed to the action of cold. 
These circumstances operate especially, when an inflamma- 
tory diathesis prevails in the system ; and, consequently, 
upon persons of the greatest vigor ; in cold climates in the 
■winter season ; and particularly in the spring, when vicissi- 
tudes of heat and cold are frequent. The disease, how- 
ever, may arise in any season when such vicissitudes occur. 

Other remote causes also may have a share in this mat- 
ter ; such as every means of obstructing, straining,* or 
otherwise injuring, f the pneumonic organs. 

Pneumonic inflammation may happen to persons of any 
age, but rarely to those under the age of puberty : and 
most commonly it affects persons somewhat advanced in 
life, as those between forty-five and sixty years ; those too, 
especially of a robust and full habit. 

* Violent exertions in speaking, ringing, playing on wind instruments, running up hill, or in 
short, any exercise that increases the action of the !un h 's. 

+ Receiving noxious vapors into the lungs issomet:mesthe cause of pneumonic inflammation; 
especially corrosive or oilier acrid poisonous vapors, as the fumes of arsenic, of sulphur, of trie 
muriatic acid, and similar caustic and destructive exhalations. Chemists, therefore, in making 
experiments, or artists who work en substances j ieldiug such vapors,, should be Literal to avoid 
t".tm. 



PRACTICE OF PHYSIC. 129 

The pneumonic inflammation has been sometimes so 
much an epidemic, as to occasion a suspicion of its de- 
pending upon a specific contagion ; but I have not met 
with any evidence in proof of this. — See Morgagni dc 
causis et sedibus morborum, epist. xxi. art. 26. 

346.] The pneumonic, like other inflammations, may 
terminate by resolution, suppuration, or gangrene ; but it 
has also a termination peculiar to itself, as has been hinted 
above (259) ; and that is, when it is attended with an effu- 
sion of blood into the cellular texture of the lungs, which 
soon interrupting the circulation of the blood through this 
viscus, produces a fatal suffocation. This, indeed, seems 
to be the most common termination of pneumonic inflam- 
mation, when it ends fatally; for, upon the dissection of 
almost every person dead of the disease, it has appeared 
that such an effusion had happened. 

347.] From these dissections also we learn, that pneumo- 
nic inflammation commonly produces an exudation from 
the internal surface of the pleura ; which appears partly as 
a soft viscid crust, often of a compact, membranous form, 
covering every where the surface of the pleura, and parti- 
culary those parts where the lungs adhere to the pleura cos- 
talis, or mediastinum ; and this crust seems always to be 
the cement of such adhesions. 

The same exudation shows itself, also, by a quantity of 
a serous whitish fluid, commonly found in the cavity of the 
thorax ; and some exudation or effusion is usually found 
to have been made likewise into the cavity of the pericar- 
dium. 

348.] It seems probable, too, that a like effusion is some- 
times made into the cavity of the bronchia? : for, in some 
persons who have died after laboring under a pneumonic 
inflammation for a few days only,, the bronchia; have been 
found filled with a considerable quantity of a serous and 
thickish fluid ; which, I think, must be considered rather 
as the effusion mentioned, having had its thinner parts tak- 
en oif by respiration, than as a pus so suddenly formed in 
the inflamed part. 

349.] It is, however, not improbable, that this effusion, 
as well as that made into the cavities of the thorax and pe- 
ricardium, may be a matter of the same kind with that 
which, in other inflammations is poured into the cellular 
texture of the parts inflamed, and there converted into pus; 
but, in the thorax and pericardium, it does not always as- 



ISO PRACTICE OF PHYSIC. 

sume that appearance, because the crust covering the sur- 
face prevents the absorption of the thinner part. This 
absorption, however, may be compensated in the bronchia; 
by the drying power of the air ; and therefore the effusion 
into them may put on a more purulent appearance. 

In many cases of pneumonic inflammation, when the 
sputa are very copious, it is difficult to suppose that the 
whole of them proceed from the mucus follicles of the bron- 
chia?. It seems more probable that a great part of them 
may proceed from the effused serous fluid we have been 
mentioning ; and this too will account for the sputa being 
so often of a purulent appearance. Perhaps the same thing 
may account for that purulent expectoration, as well as 
that purulent matter found in the bronchia' , which the learn- 
ed Mr. de Haen says he had often observed, when there 
■was no ulceration of the Jungs : and this explanation is at 
least more probable than Mr. de Haen's supposition of a 
pus formed in the circulating blood. 

350.] To conclude this subject, it would appear, that 
the effusion into the bronchiae which we have mentioned, 
often concurs with the effusion of red blood in occasioning 
the suffocation, which fatally terminates pneumonic inflam- 
mation j that the effusion of serum alone may have this ef- 
fect ; and that the serum poured out in a certain quantity, 
rather than any debility in the powers of expectoration, is 
the cause of that ceasing of expectoration which very con- 
stantly precedes the fatal event. For, in many cases, the 
expectoration has ceased, when no other symptoms of de- 
bility have appeared, and when upon dissection, the bron- 
chiae have been found full of liquid matter. Nay, it is 
feven probable, that in some cases, such an effusion may 
take place, without any symptoms of violent inflamma- 
tion ; and in other cases, the effusion taking place, may 
seem to remove the symptoms of inflammation which had 
appeared before, and thus account for those unexpected 
fatal terminations which have sometimes happened. Pos- 
sibly this effusion may account also for many of the pheno- 
mena of the Peripneumonia Notha. 

351.] Pneumonic inflammation seldom terminates by 
resolution, without being attended with some evident eva- 
cuation. An haeroorrhagy from the nose happening upon 
some of the first days of the disease, has sometimes put an 
end to it ; and it is said that an evacuation from the hemor- 
rhoidal veins, a bilious evacuation by stool, and an cvacu- 



PRACTICE OF PHYSIC. ui 

ationof urine with a copious sediment, have severally had 
the same effect: but such occurrences have been rare and 
unusual. 

The evacuation most frequently attending, and seeming 
to have the greatest effect in promoting resolution, is an 
expectoration of a thick, white, or yellowish matter, a little 
streaked with blood, copious, and brought up without ei- 
ther much or violent coughing. 

Very frequently the resolution of this disease is attended 
with, and perhaps produced by a sweat, which is warm, 
fluid, copious over the whole body, and attended with an 
•abatement of the frequency of the pulse, of the heat of the 
body and of other febrile symptoms. 

352.] The prognostics in this disease are formed from 
observing the state of the principal symptoms. 

A violent pyrexia is always dangerous. 

The danger, however, is chiefly denoted by the difficul- 
ty of breathing. When the patient can lie on one side on- 
ly; when he can lie on neither side, but upon his back on- 
ly ; when he cannot breathe with tolerable ease, except 
the trunk of his body be erect ; when, even in this pos- 
ture, the breathing is very difficult, and attended with a 
turgescence and flushing of the face, together with partial 
sweats about the head and neck, and an irregular pulse; 
these circumstances mark the difficulty of breathing in pro- 
gressive degrees, and, consequently, in proportion, the 
danger of the disease. 

A frequent violent cough aggravating the pain is always 
the symptom of an obstinate "disease. 

As I apprehend that the disease is hardly ever resolved, 
without some expectoration; so a dry cough must be al- 
ways an unfavorable symptom. 

As the expectoration formerly described, marks that the 
disease is proceeding to a resolution ; so an expectoration 
which has not the conditions there mentioned, must denote 
at least a doubtful state of the disease ; but the marks taken 
from the color of the matter, are for the most part falla- 
cious. 

An acute pain, very much interrupting inspiration, it 
always the mark of a violent disease; though not of one 
more dangerous, than an obtuse pain, attended with 
very difficult respiration. 

When the pains, which at first had affected one side on- 
ly, have afterwards spread into the other ; or when Lav- 



132 PRACTICE OF PHYSIC. 

ing the side first affected, they entirely pass into the other ; 
these are always marks of an increasing, and therefore of 
a dangerous, disease. 

A delirium coming on during a pneumonic inflammation, 
is constantly a symptom denoting much danger. 

353.] When the termination of this disease proves fatal, 
it is on one or other of the days of the first week, from the 
third to the seventh. This is the most common case ; but, 
in a few instances, death has happened at a later period of 
the disease. 

When the disease is violent, but admitting of resolution, 
this also happens frequently in the course of the first week ; 
but, in a more moderate state of the disease, the resolution 
is often delayed to the second week. 

The disease, on some of the days from the third to the 
seventh, generally suffers a remission ; which, however, may 
be often fallacious, as the disease does sometimes return 
again with as much violence as before, and then with great 
danger. 

Sometimes the disease disappears on the second or third 
day, while an erysipelas makes its appearance on some ex- 
ternal part : and if this continue fixed, the pneumonic in- 
flammation does not recur. 

354.] Pneumonia, like other inflammations, often ends 
in suppuration or gangrene.* 

355.] When a pneumonia, with symptoms neither very 
violent nor very slight, have continued for many days, it is 
to be feared it will end in a suppuration. This, however, 
is not to be determined precisely by the number of days : 
for, not only after the fourth, but even after the tenth day, 
there have been examples of a pneumonia ending by a re- 
solution ; and if the disease has suffered some intermission 
and again recurred, there may be instances of a resolution 



* As this termination of Pneumonia is always fatal, it is highly necessary that the physician 
should be able to know when a gangrene is to be suspected, that he may take the proper means 
for preventing it ; or, when it is absolutely formed, that he may save his reputation, by inform- 
ing the patient's relations of the impending danger, and the fatal consequences with which Rich a 
termination is attended : 1 shall thereiore add some of the more remarkable diagnostics of an in- 
cipient gangrene in this disease. 

A purulent spitting, streaked with deep colored blood, or with a blackish matter; a fetid 
breath ; a rattling in the throat ; a dejected countenance ; a dim eye ; a languid quick pulse ; 
Ihe blood drawn from a vein void of the inflammatory crust ; fetid green stools in abundance ; 
urine of a bright flame color, or depositing a black sediment of a scaly appearance. 

More symptoms of this fatal termination are unnecessary; for, if must of those above mention- 
ed be present, the physician has no other duty to perform than warn the friends of the patient 
that death may be soon expected. 

It may be farther remarked, that, when a gangrene is begun, the patient is considerably freed 
from pain, and both himself and his attendants have great liopesof his recovering ; a few hours, 
bowever, soon undeceives them, and raises the reputation of the physician, who has pronounced 
a true prognosis See some other diagnostic of gangrene in the notes on article 339. 



PRACTICE OF PHYSIC. 133 

happening at a much later period from the beginning of the 
disease, than that just now mentioned. 

356.] But if a moderate disease, in spite of proper re- 
medies employed, be protracted to the fourteenth day with- 
out any considerable remission, a suppuration is pretty cer- 
tainly to be expected ; and it will be still more certain, if 
ho signs of resolution have appeared, or if an expectoration 
which had appeared shall have again ceased, and the difficul- 
ty of breathing has continued or increased, while the other 
symptoms have rather abated. 

357.] That in a pneumonia, the effusion is made, which 
may lay the foundation of a suppuration, we conclude from 
the difficulty of breathing becoming greater when the pa- 
tient is in a horizontal posture,* or when he can lie more 
easily upon the affected side. 

358.] That in such cases, a suppuration has actually be- 
gun, may be concluded from the patient's being frequently 
affected with slight cold shiverings, and with a sense of cold 
felt sometimes in one, and sometimes in another part of the 
body. We form the same conclusion also from the state of the 
pulse, which is commonly less frequent and softer, but 
sometimes quicker and fuller than before. 

359.] That a suppuration is already formed, may be in- 
ferred from there being a considerable remissionf of the 
pain which had before subsisted, while along with this, the 
cough, and especially the dyspnoea, continue, and are ra- 
ther augmented. At the same time, the frequency of the 
pulse is rather increased ;% the feverish state suffers consi- 
derable exacerbations every evening, and by degrees, a 
hectic in all its circumstances comes to be formed. 

360.] The termination of pneumonia by gangrene, is 
much more rare than has been imagined ; and when it does 
occur, it is usually joined with the termination by effusion, 
(346.) and the symptoms of the one are hardly to be dis- 
tinguished from those of the other. 

361.] The cure of pneumonic inflammation, must pro- 
ceed upon the general plan (264.) but the importance of the 

• In all Pneumonic affections, the breathing is generally more difficult when the patient lies in 
»n horizontal posture; it cannot therefore be admitted as a diagnostic of an effusion. 

+ The young physician must be on Ins guard with respect to tins symptom ; for it is also a 

symptom' ot an incipient, or an already formed gangrene; he ought therefore to bo peculiarly 

attentive to the concomitant symptoms which the author enumerates, viz the continuance o( 

augmentation of the difficulty of breathing and the cough, both of which either totallj disap* 

oi Jif considerably lessened on the supervention of gangrene. 

{ i he increased frequency of the uui^e is also a symptom 01 a gangrene being formed; but, if 

requency i>c attended with febrile exacerbations in the evenings, then and thcii 

only can the physician lie sure ttM tUe disease lias terminated iu suppurativa, and not m gan> 

5 



134 PRACTICE OF PHYSIC. 

part affected, and the danger to which it is exposed, require 
that the remedies be fully, as well as early employed. 

362.] The remedy chiefly to be depended upon, is that 
of bleeding at the arm ; which will be performed with most 
advantage in the arm of the side most affected, but may be 
done in either arm, as may be most convenient for the pa- 
tient or the surgeon. The quantity drawn must be suited 
to the violence of the disease, and to the vigor of the pa- 
tient ; and generally ought to be as large as this last circum- 
stance will allow. The remission of pain, and the relief of 
respiration, during the flowing of the blood, may limit the 
quantity to be then drawn ; but if these symptoms of relief 
do not appear, the bleeding should be continued till the 
symptoms of a beginning syncope come on. It is seldom 
that one bleeding however large, will prove a cure of this 
disease. ; and although the pain and difficulty of breathing 
may be much relieved by the first bleeding, these symptoms 
commonly, and after no long interval, recur, often with as 
much violence as before. In the event of such recurrence 
the bleeding is to be repeated, even in the course of the 
same day, and perhaps to the same quantity as before. 

Sometimes the second bleeding may be larger than the 
first. There are persons who, by their constitution, are 
ready to faint even upon a small bleeding ; and in such per- 
sons this may prevent the drawing so much blood at first as 
a pneumonic inflammation might require ; but, as the same 
persons are frequently found to bear after -bleedings better 
than the first, this allows the second and subsequent bleed- 
ings to be larger, and to such a quantity as the symptoms 
of the disease may seem to demand. 

363.] It is according to the state of the symptoms, that 
bleedings are to be repeated ; and they will be more effec- 
tual when practised in the course of the first three days, than 
afterwards ; but they are not to be omitted, although four 
days of the disease may have already elapsed. If the physi- 
cian shall not have been called in sooner ; or if the bleedings 
practised during the first days shall not have been large 
enough, or even although these bleedings shall have procured 
some remission ; yet upon the recurrence of the urgent symp- 
toms, the bleeding should be repeated at any period of the 
disease, especially within the first fortnight; and even after- 
wards, if a tendency to suppuration be not evident, or if, 
after a seeming solution, the disease shall have again returned. 

361.] With respect to the quantity of blood which ought. 



PRACTICE OF PHYSIC. 135 

or which with safety may be taken away, no general rules 
cum he delivered, as it must be very different, according 
to the state of the disease and constitution of the patient. 

In an adult male of tolerable strength, a pound of blood, 
avoirdupois, is a full bleeding. Any quantity above twenty 
ounces, is a large, and any quantity below twelve a small, 
bleeding. A quantity of from four to five pounds, in the 
course of two or three days, is generally as much as such 
patients will safely bear ; but, if the intervals between the 
bleedings and the whole of the time during which the bleed- 
ings have been employed have been long, the quantity 
taken upon the whole may be greater.* 

365.] When a large quantity of blood has been already 
taken from the arm, and when it is doubtful if more can 
with safety be drawn in that manner, some blood may still 
be taken by cupping and scarifying. Such a measure will 
he more particularly proper, when the continuance or re- 
currence of pain, rather than the difficulty of breathing, 
becomes the urgent symptom ; and then the cupping and 
scarifying should be made as near to the pained part as can 
conveniently be done. 

366.] An expectoration takes place sometimes very early 
in this disease ; but if, notwithstanding that, the urgent 
symptoms should still continue, the expectoration must not 
supersede the bleedings mentioned; and during the first 
days of the disease, its solution is not to be trusted to the 
expectoration alone. It is in a more advanced stage only, 
when the proper remedies have been before employed, and 
when the symptoms have suffered a considerable remission, 
that the entire cure may be trusted to a copious and free 
expectoration. 

367.] During the first days of the disease, 1 have not 
found that bleeding stops expectoration. On the contrary, 
J have often observed bleeding promote it ; and it is in a 
more advanced stage of the disease only, when the patient, 

* Bleedings produce the best effect when the blood is drawn off as quickly as possible in a 
large lull stream ; and, in orderto prevent syncope, the patient ought to be laid horizontally, or 
id lower than Ins trunk. With respect to the quantity of blood to be drawn at 
once, or in the whole course of the disease, no general directions can lie given ; it must depend 
entirely on the circumstances of the disease and of the patient, in general, it is usual toconii- 
ge until the patient can either breathe mure freely, or fees a considerable abate- 
ment of the pam. If, however, the pain does not abate while the blood continues to flow, but 
fainting appear, the blood must then be immediate!) stopped. 
H the pain and other symptoms continue violent, or return atter the first bleeding, it will 
i v to have recourse to the operation ; and it tin's; be repeated frequently through 
the course of the disease ; avoiding, however, so large an evacuation at once as may induce 
fainting. The reason ol this precaution is evident, via. that while the motion of the heart is sus- 
during fainting, the blood stagnates in the lijlu side of the bean, and is atlerwards 
thrown with (jreater impetuosity through the lunjs. 



136 PRACTICE OF PHYSIC. 

by large evacuations and the continuance of the disease, has 
been already exhausted, that bleeding seems to stop expec- 
toration. It appears to me, that even then bleeding does 
not stop expectoration so much by weakening the powers 
of expectoration, as by favoring the serous effusion into 
the bronchia?, (348) and thereby preventing it. 

368.] While the bleedings we have mentioned shall be 
employed, it will be necessary to employ also every part 
of the antiphlogistic regimen, (130 — 132) and particularly 
to prevent the irritation which might arise from any increase 
of heat. For this purpose, it will be proper to keep the 
patient out of bed, while he can bear it easily ; and when 
he cannot, to cover him very lightly while he lies in bed. 
The temperature of his chamber ought not to exceed sixty 
degrees of Farenheit's thermometer ; and whether it may 
be at any time colder, I am uncertain. 

369.] Mild and diluent drinks, moderately tepid, at least 
never cold, given by small portions at a time, ought to he 
administered plentifully. These drinks may be impregnated 
with vegetable acids.* They may be properly accompani- 
ed also with nitre, or some other neutrals; f but these salts 
should be given separately from the drinks4 

It has been alledged, that both acids and nitre are ready 
to excite coughing, and in some persons they certainly have 
this effect; but except in persons of a peculiar habit, I have 
not found their effects in exciting cough so considerable or 
troublesome as to prevent our seeking the advantages other- 
wise to be obtained from these medicines. 

370.] Some practitioners have doubted, if purgatives 
can be safely employed in this disease ; and indeed a spon- 
taneous diarrhoea occurring in the bearinnino- of the dis- 
ease has seldom proved useful : but I have found the mo- 
derate use of cooling laxatives|| generally safe, and have 
always found it useful to keep the belly open by frequent 
emollient glysters. 

371.] To excite full vomiting by emetics, 1 judge to be 
a dangerous practice in this disease : but I have found it 
useful to exhibit nauseating doses ; and in a somewhat ad- 



» See the note on article 131. acids. + See the note on article 1(50. 

i These salts generally render the drink nauseous; and, as plentiful dilution is absolutely neces- 
sary in these cjses.so far from rendering the patient's common drink nauseous, by impregnating 
it with ili-flavoied medicines, we ought, by every possible means, to endeavor to make it as 
agreeable as we can, thai he may be the more easily prevailed on u take it plentifully. 

II The cooling laxatives are, sals, manna, &:c.but,in these cases, thice or lour ounces of iDfu- 
Sum sennze, with half an ounce of Glauber's saltmay De given without danger. 



PRACTICE OF PHYSIC. TS7 

Vanccd state of the disease, I have found such doses prove 
the best means of promoting expectoration.* 

372.] Fomentations and poultices applied to the pained 
part have been recommended, and may be useful ; but 
the application of them is often inconvenient, and may be 
entirely omitted for the sake of the more effectual remedy 
blistering, f 

Very early in the disease, a blister should be applied as 
near to the pained part as possible. But as, when the irrita- 
tion of a blister is present, it renders bleeding less effectu- 
al ; so the application of the blister should be delayed till 
a bleeding shall have been employed. If the disease be 
moderate, the blister may be applied immediately after the 
first bleeding; but if the disease be violent, and it is presum- 
ed that a second bleeding may be necessary soon after the 
first, it will then be proper to delay the blister till after 
the second bleeding, when it may be supposed that any fur- 
ther bleeding may be postponed till the irritation arisino- 
from the blister shall have ceased. It may be frequently 
necessary in this disease to repeat the blistering: and in that 
case the plaisters should always be applied somewhere on 
the thorax ;X for, when applied to more distant parts, they 
have little effect. The keeping the blistered parts open, 
and making what is called a perpetual blister, has much 
less effect than a fresh blistering. 

373.] As this disease often terminates by an expectora- 
tion, so various means of promoting this have been propos- 
ed : but none of them appear to be very effectual; and 
some of them being acrid stimulant substances, cannot be 
very safe. 

The gums usually employed seem too heating: squills 
seem to be less so; but they are not very powerful, and 
soinctimesinconvenientbytheconstantnauseatheyinduce.il 

* The tartar emetic is the medicine generallr employed for this purpose. The dose of it in 
these cases must be verv small, and well diluted, as in die following foimula : 

R. Antimon. tartarisat. gr. ii. 
Aq. font. 3viiss. 
Syr. papaveris rubr. Bss. 
M. 

The dose of this mixture ought not to exceed three table-spoonfuls, when eiven with this 
intention. 

+ rhe application of a blister to the part affected, ought to be the first prescription in all 
complaints of the thorax, except iome remarkable or urgent cause forbid the practice, because 
it is a most efficacious remedy, andis as necessary as bleeding. 

{ They ought, however, in be applied as near to the pained part as possible. 

j| All the liquid tonus of squills which we have in the shops aie nauseating. Pills made of the 
drv powder, with an electuary or conserve, orhoney, is the form in which squills affect the 
laoroach least, rhe dose is 4 or S {rains of the dry powder: 10 grains generally! it not con. 
sumly produce vomitings. 'Jo prevent the nauseating elktts ot squills," the addition of some 



ite PRACTICE OF PHYSIC. 

The volatile alkali may be of service as an expectorant • 
but it should be reserved for an advanced state of the dis- 
ease. 

Mucilaginous and oily demulcents appear to be useful 
by allaying that acrimony of the mucus which occasions 
too frequent coughing; and which coughing prevents the 
stagnation and thickening of the mucus, and thereby its 
becoming mild. 

The receiving into the lungs the steams of warm water 
impregnated with vinegar, has often proved useful in pro- 
moting expectoration.* 

But, of all other remedies the most powerful for this 
purpose, are antimonial medicines, given in nauseating do- 
ses, as in ( 179). Of these, however, I have not found the 
kermes mineral more efficacious than emetic tartar, or an- 
timonial wine ; and the dose of the kermes is much more 
uncertain than that of the others. 

374.] Though a spontaneous sweating often proves the 
crisis* of this disease, it ought not to be excited by art, un- 
less with much caution. At least I have not yet found it 
either so effectual or safe, as some writers have alledged. 
When, after some remission of the symptoms, spontaneous 
sweats of a proper kind arise they may be encouraged ; 
but it ought to be without much heat, and without stimu- 
lant medicines. If, however, the sweats be partial and 
clammy only, and a great difficulty, of breathing still re- 
main, it will be very dangerous to encourage them. 

375.] Physicians have differed much in opinion with re- 
gard to the use of opiates in pneumonic inflammation. To 
me it appears, that, in the beginning of the disease, and be- 
fore bleeding and blistering have produced some remission 
of the pain and of the difficulty of breathing, opiates have 
a very bad effect, by their increasing the difficulty of breath- 
ing, and other inflammatory symptoms. But in a more 
advanced state of the disease, when the difficuly of breath- 
ing has abated, and when the urgent symptom is a cough, 
proving the chief cause of the continuance of the pain and 

grateful aromatic is of material use. The pilula? silitica? of the Edinburgh Pharmacopoeia is a 
good formula, except that the dose of it must be 1 ;r:;e, in order to lake a sufficient quantity of 
ihe squills, 10 grains of it containing only 1 grain of dry iquilis, supposing no syrup to be used 
in making the mass. One convenience indeed, attends this formula, viz. that we can give 
small doses with more precision than if we used the powder alone. The gum ammoniac is an 
expectorant ; and therefore, when given along with the squills in these pills, may lender a less 
dose of the squills necessary. If the extract of liquorice be omitted, the proportion of the 
squills to the whole will be increased. 

* Some practitioners propose the steam of vinegar alone : but it proves in general too irritat- 
ing. The same objection may be made against using the steam of wine, which some pi I 
iloiicrs have recommended instead of the steam ot vinegar. Plain water h the bc-.t, a ti»t 
warm vapor only acts by relaxing the internal surface of itoe 1st . 



PRACTICE OF PHYSIC. 159 

of the want of sleep, opiates may be employed with great 
advantage and safety. The interruption of the expec- 
toration, which they seem to occasion, is for a short time 
only ; and they seem often to promote it, as they occasion 
a stagnation of what was by frequent coughing dissipated 
insensibly, and therefore give the appearance of what 
physicians have called Concocted Matter. 



CHAPTER VII. 

OF THE PERIPNEUMONIA NOTHA, OR 
BASTARD PERIPNEUMONY. 

376.] A DISEASE under this name is mentioned in 
Xjl some medical writings of the sixteenth cen- 
tury; but it is very doubtful if the name was then applied 
to the same disease to which we now apply it. It appears 
to me, that unless some of the cases described under the 
title of Catarrhus Suffocativus be supposed to have been 
of the kind I am now to treat of, there was no description 
of this disease given before that by Sydenham, under the 
title I have employed here. 

377.] After Sydenham, Boerhaave was the first who in a 
system took notice of it as a distinct disease ; and he has 
described it in his aphorisms, although with some circum- 
stances different from those in the description of Sydenham. 
Of late, Mr. Lieutaud has with great confidence asserted,* 
that Sydenham and Boerhaave had, under the same title, 
described different diseases ; and that, perhaps, neither of 
them had on this subject delivered any thing but hypothesis. 

378.] Notwithstanding this bold assertion, I am humbly 
of opinion, and the Baron Van Swieten seems to have been 
of the same, that Sydenham and Boerhaave did describe 
under the same title, one and the same disease. Nay, I 
am further of opinion, that the disease described by Mr. 
Lieutaud himself, is not essentially different from that des- 
cribed by both the other authors. Nor will the doubts of 
the very learned, but modest Morgagni, on this subject, 
disturb us, if we consider, that while very few describers of 
diseases cither have it in their power, or have been suffici- 
ently attentive in distinguishing between the essential and 
accidental symptoms of disease ; so, in a disease which may 



140 PRACTICE OF PHYSIC. 

have not only different, but a greater number of symp- 
toms, in one person than it has in another, we need not 
wonder that the descriptions of the same disease by dill'er- 
ent persons should come out in some respects different. I 
shall, however, enter no further into this controversy ; but 
endeavor to describe the disease as it has appeared to my- 
self: and, as I judge, in the essential symptoms, much the 
same as it has appeared to all the other authors mentioned. 

379.] Tins disease appears at the same seasons that other 
pneumonic and catarrhal affections commonly do ; that is, 
in autumn and spring. Like these diseases also, it is seem- 
ingly occasioned by sudden changes of the weather from 
heat to cold. It appears, also, during the prevalence of 
contagious catarrhs ; and it is frequently under the form of 
the Peripneumonia Notha that these catarrhs prove fatal to 
elderly persons. 

This disease attacks most commonly persons somewhat 
advanced in life, especially those of a full phlegmatic habit ; 
those who have before been frequently liable to catarrhal 
affections ; and those who have been much addicted to the 
large use of fermented and spirituous liquors. 

The disease commonly comes on with the same symptoms 
as other febrile diseases ; that is, with alternate chills and 
heats ; and the symptoms of pyrexia are sometimes suffi- 
ciently evident ; but in most cases these are very moderate, 
and in some hardly at all appear. With the first attack of 
the disease, a cough comes on ; usually accompanied with 
some expectoration, and in many cases, there is a frequent 
throwing up of a considerable quantity of a viscid opaque 
mucus. The cough often becomes frequent and violent ; is 
sometimes accompanied with a rending head-ach ; and, as 
in other cases of cough, a vomiting is sometimes excited by 
it. The face is sometimes flushed, and some giddiness or 
drowsiness often attends the disease. A difficulty of breath- 
ing, with a sense of oppression, or straitening in the chest, 
with some obscure pains there, and a sense of lassitude over 
the whole body, very constantly attend this disease. The 
blood drawn in this disease, shows a buffy surface, as in 
other inflammatory affections. 

The disease has often the appearance only of a more vio- 
lent catarrh, and after the employment of some remedies is 
entirely relieved by a free and copious expectoration. In 
other cases, however, the feverish and catarrhal symptoms 
are at first very moderate, and even slight ; but after a few 



PRACTICE OF PHYSIC. 141 

xlays, these symptoms suddenly become considerable, and 
put an end to the patient's life when the indications of 
danger were before very little evident. 

380.] From the different circumstances in which this dis- 
ease appears, the pathology of it is difficult. It is certainly 
often no other at first than a catarrhal affection, which, in 
elderly persons, is frequently attended with a large afflux of 
mucus to the lungs ; and it was on this footing that Syden- 
ham considered it as only differing in degree from his Febris 
Hyemalis. A catarrh, however, is strictly an affection of 
the mucus membrane and follicles of the bronchiae alone : 
but it may readily have, and frequently has, a degree of 
pneumonic inflammation joined to it ; and in that case may 
prove more properly the peculiar disease we treat of here. 
But, further, as pneumonic inflammation very often produ- 
ces an effusion of serum into the bronchiae (348.) so this, 
in elderlv persons, may occur in consequence of a slight 
degree of inflammation ; and when it does happen, will give 
exquisite and fatal cases of the peripneumonia notha. 

381.] After this attempt to establish the pathology, the 
method of cure in the different circumstances of the disease 
will not be difficult. 

In case the fever, catarrhal and pneumonic symptoms, 
are immediately considerable, a blood-letting will certainly 
be proper and necessary : but, where these symptoms are 
moderate, a blood-letting will hardly be requisite ; and 
when an effusion is to be feared, the repetition of blood-let- 
ting may prove extremely hurtful.* 

In all cases the remedies chiefly to be depended upon, are 
vomitingf and blistering. £ 

Full vomiting may be frequently repeated, and nauseat- 
ing doses|| ought to be constantly employed. 

Purging may perhaps be useful ; but as it is seldom so in 

•The intention of bleeding in this disease is merely to facilitate the circulation through the 
lun^s, and tort' icve the oppression in the breast; when this intention i5 theretoreanswered, and 
when the shortness of breath and oppression about the breast are removed, there is no farther 
■1. As this disease chiefly attacks elderly persons, and such as are of a phleg- 
matic habit, much harm may be done by repeated bleedings, which always increase debility and 
retard the cure, 
+ Vomiting, in this disease, has been thought bv manv practitioners to be a doubtful remedy. 
m ol vomiting always oppresses the breast, and sometimes even increases the symp- 
tom! of the disease. 

t Ibis is the chief remedy : and the blisters ought to be applied as near the part affected as 
possible. 
II In several of the former Notes we have fully described the method of giving the emetic tar- 
Thru principal effect is to procure a perspiration . : and, when this 
il -mist drink hugely of any diluent or attenuating liquor, as thin 
addition of the juice ot some of the acid Iruits, or lulu.ioosof some of 
-, .aje, balm, mint, &c. or even a thiu wine whey. 



142 PRACTICE OF PHYSIC. 

pneumonic affections, nothing but gentle laxatives are here 
necessary.* 

In all the circumstances of this disease, the antiphlogistic 
regimen is proper ; cold is to be guarded against ; but much 
external heat is to be as carefully avoided. 

382.] If a person sweats easily, and it can be brought 
out by the use of mild tepid liquors only, the practice may 
in such persons be tried. See Morgagni de Sed. et Caus. 
Epist. xiii. Art. 4. 

383.] I might here, perhaps, give a separate section on 
the Carditis and Pericarditis, or the inflammations of the 
Heart and Pericardium ; but they hardly require a particu- 
lar consideration. An acute inflammation of the pericardi- 
um is almost always a part of the same pneumonic affection 
I have been treating of ; and is not always distinguished by 
any different symptoms : or, if it be, does not require any 
different treatment. The same may be said of an acute in- 
flammation of the heart itself ; and when it happens that 
the one or other is discovered by the symptoms of palpita- 
tion or syncope, no more will be implied than that the reme- 
dies of pneumonic inflammation should be employed with 
greater diligence. 

From dissections, which shew the heart and pericardium 
affected with erosions, ulcerations, and abscesses, we disco- 
ver, that these parts had been before affected with inflam- 
mation : and that in cases where no symptoms of pneumo- 
nic inflammation had appeared ; it may therefore be alledg- 
ed, that those inflammations of the heart and pericardium 
should be considered as diseases independent of the pneu- 
monic. This indeed is just ; but the history of such cases, 
proves that those inflammations had been of a chronic kind, 
and hardly discovering themselves by any peculiar symp- 

* Purging is surely hurtful in this disease, by inducing too great a state of debility : the intes- 
tines, however, are to be emptied in the beginning of the disease, which is best done by a 
purging glvster, and kept open by the subsequent use of gentle laxatives, or by repetitions «f 
mild emollient glysters The purging glyster may be made as follows : 

R. Aq. font. lb. I. 
Fol. Senn. §ss. 

Coque leniter, et colaturat adde 
Sal. Cathart. ama. Si- 
Mel. Bii. 
M. f. Enema. 

The subsequent glysters ought to consist of nothing more than simple barley-water, or milk and 
water. The laxatives, if they are used, should be very gentle and mild ; as cream of tartar, 
whev, manna, tamarinds, &c. Halt an ounce of manna dissolved in half a pint of cream of 
tartar whey, makes an a;reeable opening mixture ; half a tea-cupful of it may be taken three 
or four times a day, so as to procure at least twu or thre« stools in the twenty -tour hour*. 



PRACTICE OF PHYSIC. 143 

loms ; or if attended with symptoms marking an affection 
of the heart, these were however such as have been knoAvn 
frequently to arise from other causes than inflammation. 
There is, therefore, upon the whole, no room for our treat- 
ing more particularly of the inflammation of the heart or 
pericardium. 



CHAPTER VIII. 



OF THE GASTRITIS, OR INFLAMMATION 
OF THE STOMACH. 

384.] A MONG the inflammations of the abdominal 
a\. region, I have given a place in our Nosology 
to the Peritonitis; comprehending under that title, not on- 
ly the inflammations affecting the peritonaeum lining the ca- 
vity of the abdomen, but also those affecting the extentions 
of this membrane in the omentum and mesentery. It is not, 
however, proposed to treat of them here, because it is ve- 
ry difficult to say by what symptoms they are always to be 
known; and farther, because when known, they do not re- 
quire any remedies beside those of inflammation in gener- 
al. I proceed therefore, to treat of those inflammations, 
which affecting viscera of peculiar functions, both give 
occasion to peculiar symptoms, and requires some peculi- 
arities in the method of cure; and I shall begin with the 
inflammation of the stomach. 

385.] The inflammation of the stomach is of two kinds, 
Phlegmonic, or Ervthematic* The first may be seated in- 
what is called the Nervous Coat of the stomach, or in the 
peritonaeum investing it. The second is always seated in 
the villous coat and cellular texture immediately subjacent. 
386.] The phlegmonic inflammation of the stomach, or 
what has been commonly treated of under the title of Gastri- 
tis, is known by an acute pain in some part of the region 
of the stomach, attended with pyrexia, with frequent vom- 
iting, especially upon occasion of an}' thing being taken 
down into the stomach, and frequently with hickup. The 
pulse is commonly small and hard ; and there is a greater 
loss of strength in all the functions of the body, than in the 
case of almost any other inflammation. 

• This is a new term ; but whoever considers what is laid in 374, will, 1 «xp«ct, peiceire fke 
{uropriety, and even tlie necessity, ot ti. 



144 PRACTICE OF PHYSIC. 

387.] This inflammation may be produced by various 
causes ; as, by external contusion ; by acrids of various 
kinds taken into the stomach; frequently by very cold 
drink taken into it while the body is very warm ; and some- 
times by over-distension, from the having taken in a large 
quantity of food of difficult digestion. All these may be 
considered as external causes; but the disease sometimes 
arises also from internal causes not so well understood. It 
may arise from inflammations of the neighboring parts com- 
municated to the stomach, and is then to be considered as 
a symptomatic affection only. It may arise also from va- 
rious acrimonies generated within the bodv, either in the 
stomach itself, or in other parts, and poured into the cavity 
of the stomach. These are causes more directly applied 
to the stomach; but there are perhaps others originating 
elsewhere, and affecting the stomach only sympathetical- 
ly. Such may be supposed to have acted in the case of pu- 
trid fevers andexanthematic pyrexia; in which, upon dis- 
section, it has been discovered that the stomach had been 
affected with inflammation. 

388.] From the sensibility of the stomach, and its com- 
munication with the rest of the system, it will be obvious, 
that the inflammation of this organ, by whatever causes 
produced, may be attended with fatal consequences. In 
particular, ,by the great debility which such an inflamma- 
tion suddenly produces, it may quickly prove fatal, with- 
out running the common course of inflammations. 

When it lasts long enough to follow the ordinary course 
of other inflammations, it may terminate by resolution, 
gangrene, or suppuration. The scirrhosities which are of- 
ten discovered affecting the stomach, are seldom known to 
be the consequences of inflammation. 

389.] The tendency of this disease to admit of resolu- 
tion, may be known, by its having arisen from no violent 
cause ; by the moderate state of the symptoms ; and by a 
gradual remission of these, especially in consequence of re- 
medies employed in the course of the first, or at farthest, 
the second week of the disease. 

390.] The tendency to suppuration may be known by 
the symptoms continuing, in a moderate degree, for more 
than one or two weeks ; and likewise by a considerable re- 
mission of the pain, while a sense of weight and an anxiety 
still remain. 

When an abscess has been formed, the frequency of the 



PRACTICE OF PHYSIC. 145 

pulse is at first abated ; but soon after, it is again increased, 
■with frequent cold sbiverings, and with marked exacerba- 
tions in the afternoon and evening, followed by night 
sweatings, and other symptoms of hectic fever. These at 
length prove fatal, unless the abscess open into the ca- 
vity of the stomach, the pus be evacuated by vomiting 
and the ulcer soon heal. 

391.] The tendency to gangrene may be suspected from 
the violence of the symptoms not yielding to the remedies 
employed during the first days of the disease : and that a 
gangrene has already begun, may be known from the sud- 
den remission of the pain, while the frequency of the pulse 
continues, and at the same time becomes weaker, accom- 
panied with other marks* of an increasing debility in the 
whole system. 

392.] From the dissection of dead bodies it appears, 
that the stomach very often has been affected with inflam- 
mation, when the characteristic symptoms of it (386.) had 
not appeared ; and therefore it is very difficult to lay down 
any general rules for the cure of this disease. 

393.] It is only in the case of phlegmonic inflammation, as 
characterised in (336.) that wecan advisethe cure or resolu- 
tion to be attempted by large and repeated bleedings em- 
ployed early in the disease: and we are not to be deterred 
from these by the smallness of the pulse ; for after bleed- 
ing, it commonly becomes fuller and softer. After bleed- 
ing, a blister ought to be applied to the region of the sto- 
mach ; and the cure will be assisted by fomentations of the 
whole abdomen, as well as by frequent emollient and lax- 
ative glysters. 

394.] In this disease, the irritability of the stomach will 
not admit of any medicines being thrown into it ; and if 
any internal medicines can be supposed necessary, they 
must be exhibited in glysters. The giving of drink may 
be tried ; but it ought to be of the very mildest kind, and 
in very small quantities at a time. t 

395.] Opiates, in whatever manner exhibited, are very 
hortful during the first days of the disease ; but when its 
violence shall have abated, and when the violence of the 
pain and vomiting recur at intervals only, opiates given in 

iliriurn is one of the most general concomitants of the increasing debility of the system, 
and in 

, it may be taken in small quantities, with about ei<;ht or 
il o( it. Lintseed lea , mild drink; and, if t'liein- 

i the presence ot any acrid matter iniuuug the stomach, it m of great 

by us iUeatluug quality. 



146 PRACTICE OF PHYSIC. 

glysters may be cautiously tried, aud sometimes have been 
employed with advantage. 

396.] A tendency to suppuration, in this disease, is to 
be obviated by the means just now proposed. After a 
certain duration of the disease, it cannot be prevented by 
any means whatever ; and when actually begun must be 
left to nature ; the business of the physician being only to 
avoid all irritation. 

397.] A tendency to gangrene can be obviated in no 
other way than by the means suggested, (393.) employed 
early in the disease ; and, when it does actually supervene, 
admits of no remedy. 

398.] Erythematic inflammations of the stomach, are 
more frequent than those of the phlemonic kind. It ap- 
pears at least, from dissections, that the stomach has often 
been affected with inflammation, when neither pain nor py- 
rexia had before given any notice of it ; and such inflam- 
mation I apprehend to have been chiefly of the erythematic 
kind. This species of inflammation also is especially to be 
expected from acrimony of any kind thrown into the sto- 
mach; and would certainly occur more frequently from such 
a cause, were not the interior surfaceof this organ common- 
ly defended by mucus exuding in large quantities from the 
numerous follicles placed immediately under the villous 
coat. Upon many occasions, however, the exudation of 
mucus is prevented, or the liquid poured out is of a less 
viscid kind, so as to be less fitted to defend the subjacent 
nerves ; and it is in such cases that matters even of mode- 
rate acrimony, may produce an erythematic affection of 
the stomach. 

399.] From what has been said, it must appear that an 
erythematic inflammation of the stomach may frequently 
occur ; but will not always discover itself, as it sometimes 
takes place without pyrexia, pain, or vomiting. 

400.] There are cases, however, in which it may be dis- 
covered. The affection of the stomach sometimes spreads 
into the oesophagus, and appears in the pharynx, as well 
as on the whole internal surface of the mouth. When, 
therefore, an erythematic inflammation affects the mouth 
and fauces, and when at the same time there shall be in the 
stomach an unusual sensibility to all acrids, with a frequent 
vomiting, there can be little doubt of the stomach being 
affected with the same inflammation that has appeared in 
tfee fauces. Even when no inflammation appears in the 



PRACTICE OF PHYSIC. 147 

fauces yet if some degree of pain be felt in the stomach, 
if there be a want of appetite, an anxiety, frequent vom- 
iting, an unusual sensibility, with respect to acrids, some 
thirst, and frequency of pulse, there will then be room to 
•uspect an erythematic inflammation of the stomach ; and 
we have known such symptoms, after some time, discover 
their cause more clearly by the appearance of the inflam- 
mation in the fauces or mouth. Erythematic inflamma- 
tion is often disposed to spread from one place to another 
on the same surface ; and, in doing so, to leave the place 
it had at first occupied. Thus, such an inflammation has 
been known to spread successively along the whole course 
of the alimentary canal, occasioning in the intestines diar- 
rhoea, and in the stomach vomitings; the diarrhoea ceasing 
when the vomitings came on, or the vomitings upon the 
coming on of the diarrhoea. 

401.] When an erythematic inflammation of the sto- 
mach shall be discovered, it is to be treated differently, ac- 
cording to the difference of its causes and symptoms. 

When it is owing to acrid matters taken in by the mouth, 
and when these may be supposed still present in the stom- 
ach, they are to be washed out by throwing in a large 
quantity of warm and mild liquids, and by exciting vomit- 
ing. At the same time, if the nature of the acrimony and 
its proper corrector be known, this should be thrown in ; 
or if a specific corrector be not known, some general de- 
mulcents should be employed. 

402.] These measures, however, are more suited to pre- 
vent the inflammation, than to cure it after it has taken 
place. When this last may be supposed to be the case, if 
it be attended with a sense of heat, with pain and pyrexia, 
according to the degree of these symptoms, the measures 
proposed in (393) are to be more or less employed. 

403.] When an erythematic inflammation of the stomach 
has arisen from internal causes, it pain and pyrexia accom- 
pany the disease, some bleeding in persons not otherwise 
weakened, may be employed ; but, as the affection often 
arises in putrid diseases, and in convalescents from fever; 
so in these cases, bleeding is inadmissible; all that can be done 
being to avoid irritation, and to throw into the stomach 
what quantity of acids, and of acescent aliments, it shall 
be found to bear. 

In some conditions of the body, in which this disease 
arises, the Peruvian bark and bitters may seem to be indi- 



143 PRACTICE OF PHYSIC. 

cated : but an erythematic state of the stomach does not 
commonly allow of them. 



CHAPTER IX. 

OF THE ENTERITIS, OR INFLAMMATION 
OF THE INTESTINES. 

404.] r T^HE inflammation of the intestines, like that of 
JL the stomach, may be either phlegmonic or 
erythematic ; but, on the subject of the latter, I have no- 
thing to add to what has been said in the last chapter; and 
shall here therefore treat of the phlegmonic inflammation only. 

405.] This inflammation may be known to be present, 
by a fixed pain of the abdomen, attended with pyrexia, 
costiveness, and vomiting. Practical writers mention the 
pain in this case as felt in different parts of the abdomen, 
according to the different seat of the inflammation ; and so, 
indeed, it sometimes happens ; but very often the pain 
spreads over the whole belly, and is feit more especially 
about the navel. 

406.] The Enteritis and Gastritis arise from like causes ; 
but the former, more readily than the latter, proceeds from 
cold applied to the lower extremities, or to the belly itself. 
The enteritis has likewise its own peculiar causes, as super- 
vening upon the spasmodic colic, incarcerated hernia, and 
volvulus. 

407.] Inflammations of the intestines have the same ter- 
minations as those of the stomach ; and, in both cases, the 
several tendencies are to be discovered by the same symp- 
toms (389. 391.) 

408.] The cure of the enteritis is, in general, the same 
with that of the gastritis; (393. and seq.) but in the ente- 
ritis, there is commonly more access to the introduction of 
liquids, of acid, acescent, and ether cooling remedies, and 
even of laxatives.* As, however a vomiting so frequently 

•In this disease, we ought to be extremely cautious in the administration either of medi- 
cines or diluents. The reason is evident from the- following considerations. In every case of 
inflammation ot a canal, the bore of that canal is diminished, and frequently quite shut. A 
euantity of any kind of ingesta being forced agnint this obstruction, must necessarily increase. 
the irritation, and consequently aggravate al i reason may I 

for the caution necessary in prescribing laxatives, which always itritate; for tli 
rally depends upon the irritation they produce. Large bleedings, emollient glvsters fi 
repeated, fomentations, the warm bath, and sma'I 
tine most stfectual remedies in the first .tag . of tin. violent dueMC Wuen tiic pain lemitk, anil 



PRACTICE OF PHYSIC. 149 

attends this disease, care must be taken not to excite that 
vomiting by either the quantity or the quality, of any thing 
thrown into the stomach. 

The same observation with respect to the use of opiates 
is to be made here as in the case of gastritis. 

409.] Under the title of Enteritis, it has been usual with 

f>ractical writers to treat of the remedies proper for the cho- 
ic* and its higher degree named Ileus : but, although it be 
true that the enteritis and cholic do frequently accompany 
each other, I still hold them to be distinct diseases, to be of- 
ten occurring separately, and accordingly to require and ad- 
mit of different remedies. I shall therefore delay speaking 
of the .remedies proper for the cholic, till I shall come to 
treat of this disease in its proper place. 

410.] What might be mentioned with respect to the sup- 
puration or gangrene occurring in the enteritis, may be suf~ 
ficiently understood from what has been said on the same sub- 
ject with respect to the gastritis. 



CHAPTER X. 

OF THE HEPATITIS, OR INFLAMMATION 
OF THE LIVER. 

411.] r T" , HE inflammation of the liver seems to be of 
X two kinds ; the one acute, the other chronic. 

412.] The acute is attended with pungent pain; consid- 
erable pyrexia ; a frequent, strong, and hard pulse ; and 
high colored urine. 

413.] The chronic hepatitis very often does not exhibit 

the violence of the symptoms abates, mild diluents may then be admitted, as chicken-broth, 
thin Imtseed tea, &c. ; and, if such liquors be retained without aggravating the symptoms, we> 
may then venture to give an ounce ot manna every three or four hours, till it procures a pas- 

The internal use of opium has been extolled by several practitioners in these cases ; but ex- 
perience shews that it generally does harm in every case of inflammation, especiaJly in the 
early stages of it. 

I he inodvne glyster is the safest method ot using opium ; butglysters of this kind are said fo 
obstruct: This objection is, however, ill founded; for, by diminishing the irritation, they evi- 
dently tend to rciolve the inflammation. The following formula of an anodvne glyster is gent- 
rally used : wv " 

R. Decoct, hord. ?iv. 
Opii puri gr. iv. 
M. 

In these glysters, particular care must be taken to avoid every thine that has the least tendea- 
Of in irrnate. 

e be formed before the physician be called, as is too frequently the case, then aM 
remedies are in vain. 
• See truck- 4K>. 



159 PRACTICE OF PHYSIC. 

any of these symptoms ; and it is only discovered to hare 
happened, by our finding in the liver, upon dissection, 
large abscesses, which are presumed to be the effect of some 
degree of previous inflammation. As this chronic inflam- 
mation is seldom to be certainly known, and therefore docs 
not lead to any determined practice, we omit treating of it 
here, and shall only treat of what relates to the acute spe. 
cies of the hepatitis.* 

414.] The acute hepatitis may be known by a pain more 
or less acute in the right hypochondrium, increased by pres- 
sing upon the part. The pain is very often in such a part 
of the side as to make it appear like that of a pleurisy ; and 
frequently, like that too, is increased on respiration. The 
disease is, in some instances, also attended with a cough 
which is commonly dry, but sometimes humid: and when 
the pain thus resembles that of a pleurisy, the patient can- 
not lie easily except upon the side affected. 

In every kind of acute hepatitis, the pain is often extend- 
ed to the clavicle, and to the top of the shoulder. The dis- 
ease in attended sometimes with hickup, and sometimes with 
vomiting. Many practical writers have mentioned the jaun- 
dice, or a yellow color of the skin and eyes, as a very con- 
stant symptom of the hepatitis ; but experience has shown, 
that it may often occur without any such symptom, f 

415.] The remote causes of hepatitis are not always to 
be discerned, and many have been assigned on a very uncer- 
tain foundation. The following seem to be frequently evi- 
dent. 1. External violence from contusions or falls, and es- 
pecially those which have occasioned a fracture of the 
cranium. 2. Certain passions of the mind. 3. Violent 
summer heats. 4. Violent exercise. 5. Intermittent and 
remittent fevers. 6. Cold applied externally, or internal- 
ly ; and therefore in many cases the same causes which pro- 
duce pneumonic inflammation, produce hepatitis ; and 
whence also the two diseases are sometimes joined together. 
7. Various solid concretions or collections of liquid mat- 
ter, in the substance of the liver, produced by unknown 
causes. Lastly, The acute is often induced by a chronic 
inflammation of this viscus. 

416.] It has been supposed, that the hepatitis may be an 
affection either of the extremities of the hepatic artery, or 

* It is doubtful whe:her tliis chronic hepatitis ever exists. 

+ This 5\mptorn generally appears, however, after the disease has continued for three or four 
days ; perhaps, indeed, it might have been present in the beginning, for it is frequently so slight 
as to escape observatioa. 



PRACTICE OF PHYSIC. 151 

of those of the vena potanim ; but of the last supposition 
there is neither evidence nor probability. 

417.] It seems probable, that the acute hepatitis is al- 
ways an affection of the external membrane of the liver; 
and that the parenchymatic is of the. chronic kind. The 
acute disease may be seated either on the convex or on the 
concave surface of the liver. In the former case, a more 
pungent pain and hickup may be produced, and the res- 
piration is more considerably affected. In the latter, there 
occurs less pain ; and a vomiting is produced, commonly 
by some inflammation communicated to the stomach. The 
inflammation of the concave surface of the liver, may be 
readily communicated to the gall bladder and biliary ducts; 
and this perhaps is the only case of idiopathic hepatitis at- 
tended with jaundice. 

418.] The hepatitis, like other inflammations, may end 
by resolution, suppuration, or gangrene ; and the tenden- 
cy to the one or the other of these events, may be known 
from what has been delivered above. 

419.] The resolution of hepatitis is often the conse- 
quence of, or is attended with, evacuations of different 
kinds. A hemorrhagy, sometimes from the* right nostril, 
and sometimes from the hemorrhoidal vessels, gives a so- 
lution of the disease. Sometimes a bilious diarrhoea con- 
tributes to the same event ; and the resolution of the hepa- 
titis, as of other inflammations, is attended with sweating, 
and with an evacuation of urine, depositing a copious se- 
diment. Can this disease be resolved by expectoration ? 
It would seem to be sometimes cured by an erysipelas ap- 
pearing in some external part. 

420.] When this disease has ended in suppuration, the 
pus collected may be discharged by the biliary ducts ; or, 
if the suppurated part does not any where adhere closely 
to the neighboring parts, the pus may be discharged into 
the cavity of the abdomen; but if, during the first state of 
inflammation, the affected part of the liver shall have 
formed a close adhesion to some of the neighboring parts, 
the discharge of the pus after suppuration may be various, 
according to the different seat of the abscess. When seat- 
ed on the convex part of the liver, if the adhesion be to 
the peritonaeum lining the common teguments, the pus 

* And tlie left also. It was a fancy of Galen's that inflammatory fevers were onlv resolved br 
lowed from the side affected i Thus, an hemorrhage from the right nostril, 
resolved aa iniUmnutiun ot Ui* livers but a discharge how m« left, au milauiniatiuu of the 
<»leen. 



152 PRACTICE OF PHYSIC. 

may make its way through these, and be discharged out- 
wardly; or, if the adhesion should have been to the dia- 
phragm, the pus may penetrate through this, and into the 
cavity of the thorax, or of the lungs ; and through the 
latter may be discharged by coughing. When the abscess 
of the liver is seated on its concave part, then, m conse- 
quence of adhesions, the pus may be discharged into the 
stomach or the intestines ; and into these last, either di- 
rectly, or by the intervention of the biliary ducts. 

421.] The prognostics in this disease are established up- 
o.n the general principles relating to inflammation, upon the 
particular circumstances of the liver, and upon the parti- 
cular state of its inflammation. 

The cure of this disease must proceed upon the general 
plain ; by bleeding, more or less, according to the urgency 
of pain or pyrexia ; by the application of blisters ; by fo- 
mentations, of the external parts in the usual manner, and 
of the internal parts by frequent emollient glysters ; by fre- 
quently opening the belly by means of gentle laxatives, and 
by diluent and refrigerant remedies, 

422.] Although, in many cases the chronic hepatitis does 
not clearly discover itself; yet upon many occasions, it may 
perhaps be discovered, or at least suspected from those causes 
which might affect the liver (316.) having been applied ; from 
some fulness and some tenseness of weight in the right hy- 
pochondrium ; from some shooting pains at times felt in that 
region ; from some uneasiness or pain felt upon pressure iii 
that part ; from some uneasiness from lying upon the left 
side ; and lastly, from some degree of pyrexia, combined 
with more or fewer of these symptoms. When from 
some of these circumstances a chronic inflammation is to be 
suspected, it is to be treated by the same remedies as in the 
last paragraph, employed more or less, as the degree of the 
several symptoms shall more distinctly indicate. 

423.] When from either kind of inflammation a sup- 
puration of the liver has been formed, and the abscess 
points outwardly, the part must be opened, the pus evacuat- 
ed, and the ulcer healed according to the ordinary rules for 
cleansing and healing such abscesses and ulcers. 

424.] I might here consider the Splenitis, or inflamma- 
tion of the spleen ; but it does not seem necessary, because 
the disease very seldom occurs. When it does, it may be 
readily known by the character given in our Nosology ; 
and its various termination, as well as the practice which 



PRACTICE OF PHYSIC. 153 

it requires, may be understood from what has been already 
said with respect to the inflammations of the other abdo- 
minal viscera. i 



unnal viscera. 



CHAPTER XI. 

OF THE NEPHRITIS, OR THE INFLAM- 
MATION OF THE KIDNEYS. 

425.] r TTHIS disease, like other internal inflammations, 
A is alway attended with pyrexia ; and is es- 
pecially known from the region of the kidney being affected 
by pain, commonly obtuse, sometimes pungent. This pain 
is not increased by the motion of the trunk of the body, so 
much as a pain of the rheumatic kind affecting the same 
region. The pain of the nephritis may be often distin- 
guished by its shooting along the course of the ureter ; and 
is frequently attended with a drawing up of the testicle, 
and with a numbness of the limb on the side affected ; al- 
though, indeed, these symptoms most commonly accom- 
pany the inflammation arising from a calculus in the kid- 
ney or in the ureter. The nephritis is, almost constantly 
attended with frequent vomiting, and often with costive- 
ness and cholic pains. Usually the state of the urine is 
changed ; it is most commonly of a deep red color, is 
voided frequently, and in small quantity at a time. In 
more violent cases, the urine is sometimes colorless. 

426.] The remote causes of this disease may be various ; 
as, external contusion ; violent or long continued riding ; 
strains of the muscles of the back incumbent on the kid- 
neys; various acrids in the course of the circulation con- 
veyed to the kidneys ; and perhaps some other internal 
causes not yet well known. The most frequent is that of 
calculous matter obstructing the tubuli, uriniferi, or calculi 
formed in the pelvis of the kidneys, and either sticking 
there, or fallen into the ureter. 

427.] The various event of this disease may be under- 
stood from what has been delivered on the subject of other 
inflammations, 

428.] Writers, in treating of the cure of nephritis, have 
commonly at the same time treated of the cure of the Cal- 
culus renalis ; but, though this may often produce ne- 



154 PRACTICE OF PHYSIC. 

P'iritis, it is to be considered as a distinct and separate dis- 
ease ; and what I have to offer as to the mode of treating 
it, must be reserved to its proper place. Here I shall 
treat only of the cure of the Nephritis Vera or Idiopathica. 

429.] The cure of this proceeds upon the general plan 
by bleeding, external fomentation, frequent emollient 
glysters, antiphlogistic purgatives, and the free use of mild 
and demulcent liquids.* The application of blisters is hard- 
ly admissible; or, at least, will require great care, to avoid 
any considerable absorption of the cantharides.f 

430.] The Cystitis, or inflammation of the bladder u 
seldom a primary disease; and therefore is not to be treat- 
ed of here. The treatment of it, so far as necessary to be 
explained, may be readily understood from what has been 
already delivered. 

431.] Of the visceral inflammations, there remains to be 
considered the inflammation of the Uterus ; but I omit it 
here, because the consideration of it cannot be separated 
from that of the diseases of child-bearing women. 

• These have all been enumerated in some of the preceding notes. 

+ This is a very necessary caution. Blisters generally affect the urinary organs and Tesseli 
occasioning much irritation, and consequently increasing the inflammation As the author is 
rather short in his direciions for the cure of this very troublesome inflammation, it may be pro- 
per to add some particular directions for regulating our practice in these cases. 

An ulcer in the kidneys is extremely difficult to heal; we ought therefore always to attempt 
the cure of nephritis by resolution. The general remedies for answering this intention have 
been frequently enumerated, especially in the notes on art. 130— 131.— The particular remedies 
more peculiarly adapted to this disease are dumulcent drinks of the softest nature, and such as 
are least apt to irritate the parts ; as lintseed-tea, decoction of marsh-mallows, &c. Nitre has- 
been recommended among the general aniiphlogislic remedies; but, in nephritis its use is 
doubtful, on account of its passing quickly by the kidneys, and irritating them. 

A difficulty of making water is one of the symptoms of this disease, and some practitioners 
recommend heating diuretics. This practice, however, is extremely hurtful, and ought to be 
«arefully avoided, because these warm medicines, as turpentines, balsams, &c. always increase 
the irritation, especially in the urinary passages. 

As the colon presses immediately on the kidneys, especially on the right one, we should he 
peculiarly careful to keep it empty, which is best done by glysters. Beside the use of glysters in 
evacuating the contents of the colon, they act as a fomentation to the inflamed part ; we ought 
therefore, in these cases, to prescribe them larger than usual, and repeat them ofien. They 
ought to be extremely emollient, and void of every ingredient that is any way stimulating. A 
quart of thin barley-water or lintseed-tea answers the purpose as completely as any of the more 
•ompound emollient glysters of the Pharmacopoeias. 

With respect to diet and regimen, we may observe that lenient nourishment is highly proper; 
for every thing acrid naturally forces itself off by the urine, and consequently increases the irri- 
tation. A total abstinence from food is by no means adviseable, because, from abstinence. 
little urine is secreted, and the smaller the quantity secreted it is generally the more acrid, ana 
eonsequently noxious. 

The patient ought to be made to sit up as much as possible. Warm soft beds, which are al- 
ways improper in all inflammatory diseases, are peculiarly hurtful in nephritis, especially if the 
patient lies on his back ; for in this position the kidneys are kept very warm, and are at the 
same time pressed by the superincumbent weight of the abdominal viscera, all which will con- 
tribute to increase the inflammation. Although lying much in bed be disapproved, the patient 
ought by no means to be over fatigued with sitting too long. The room should be moderately 
cool, and the bed springy, but not soft 

In addition to what was said above respeciingblisters in this disease, it may be necessary to ob- 
serve, that other vesicants belles cantharides may be used, such as mustard pouluccs, common- 
1 1 called sinapisms, a poulrtcc of die fresb leaves of the ranunculus acris, and other acrid plants. 



PRACTICE OF PHYSIC. \ss 



CHAPTER. XII. 

OF THE RHEUMATISM. 

432.] /^\F this disease there are two species, the one 
V_y named the Acute, the other the Chronic 
rheumatism. 

433.] It is the acute Rheumatism which especially be- 
longs to this place, as from its causes, symptoms, and me- 
thods of cure, it will appear to be a species of phlegmasia 
or inflammation. 

434.] This disease is frequent in cold, and more uncom- 
mon in warm climates. It appears most frequently in au- 
tumn and spring, less frequently in winter when the cold is 
considerable and constant, and very seldom during the heat 
of summer. It may occur, however, at any season, if vi- 
cissitudes of heat and cold be for the time frequent. 

435.] The acute rheumatism generally arises from the 
application of cold to the body when any way unusually 
warm ; or when one part of the body is exposed to cold 
whilst the other parts are kept warm ; or, lastly, when the 
application of the cold is long continued, as it is when wet 
or moist clothes are applied to any part of the body. 

436.] These causes may affect persons of all ages ; but 
the rheumatism seldom appears in either very young or in 
elderly persons, and most commonly occurs from the age of 
puberty to that of thirty-five years. 

437.] These causes (435.) may also affect persons of 
any constitution ; but they most commonly affect those of 
a sanguine temperament. 

438.] This disease is particularly distinguished by pains 
affecting the joints, for the most part the joints alone, but 
sometimes affecting also the muscular parts. Very often 
the pains shoot along the course of the muscles, from one 
joint to another, and are always much increased by the ac- 
tion of the muscles belonging to the joint or joints affected. 

439.] The larger joints are most frequently affected ; such 
as the hip-joint and knees of the lower, and the shoulders 
arid elbows of the upper extremities. The ankles and 
u lists are also frequently affected ; but the smaller joints, 
such as those of the toes or fingers, seldom suffer. 

4 1-0. j This disease although sometimes confined to one part 



156 PRACTICE OF PHYSIC. 

of the body only, yet very often affects many parts of it ; and 
then it comes on with a cold stage, which is immediately 
succeeded by the other symptoms of pyrexia and particu- 
larly by a frequent, full, and hard pulse. Sometimes the 
pyrexia is formed before any pains are perceived ; but more 
commonly pains are felt in particular parts, before any 
symptoms of pyrexia appear. 

441.] When no pyrexia is present, the pain is sometimes 
confined to one joint only ; but, when any considerable py- 
rexia is present, although the pain may be chiefly in one 
joint, yet it seldom happens but that the pains affect seve- 
ral joints often at the very same time, but for the most part 
shifting their place, and having abated in one joint, become 
more violent in another. They do not commonly remain 
long in the same joint, but frequently shift from one to ano- 
ther, and sometimes return to joints formerly affected ; and 
in this manner the disease often continues for a long time. 

442.] The pyrexia attending this disease has an exacerba- 
tion every evening, and is most considerable during the 
night, when the pains also become more violent ; and it is 
at the same time that the pains shift their place from one 
joint to another. The pains seem to be also increased dur- 
ing the night, by the body being covered more closely, and 
kept warmer. 

443.] A joint, after having been for some time affected 
with pain, commonly becomes affected also with some red- 
ness and swelling, which is painful to the touch. It seldom 
happens, that a swelling coming on does not alleviate the 
pain of the joint ; but the swelling does not always take off 
the pain entirely, nor secure the joint against a return of it. 

444.] This disease is commonly attended with some 
sweating, which occurs early in the course of the disease ; 
but it is seldom free or copious, and seldom either relieves 
the pains or proves critical. 

445.] In the course of this disease the urine is high co- 
lored, and in the beginning without sediment ; but as the 
disease advances, and the pyrexia has more considerable 
remissions, the urine deposits a lateritious sediment. This, 
however, does not prove entirely critical ; for the disease 
often continues long after such a sediment has appeared in 
the urine. 

446.] When blood is drawn in this disease, it always ex- 
hibits the appearance mentioned (237.) 

447.] The acute rheumatism, though it has so much 



PRACTICE OF PHYSIC. 157 

of the nature of the other phlegmasia, differs from all those 
hitherto mentioned, in this, that it is not apt to terminate 
in suppuration. This almost never happens in rheumatism ; 
but the disease sometimes produces effusions of a transpa- 
rent gelatinous fluid into the sheaths of the tendons. If 
we may be allowed to suppose that such effusions are fre- 
quent, it must also happen, that the effused fluid is com- 
monly reabsorbed ; for it has seldom happehed, and never 
indeed to my observation, that considerable or permanent 
tumors have been produced, or such as required to be 
opened, and to have the contained fluid evacuated. Such 
tumors, however, have occurred to others, and the open- 
ing made in them has produced ulcers difficult to heal. 
Vide Storck. Ann. Med. II. 

448.] With the circumstances mentioned from (438. to 
447.) the disease often continues for several weeks. It sel- 
dom, however, proves fatal ; and it rarely happens that the 
pyrexia continues to be considerable for more than two or 
three weeks. While the pyrexia abates in its violence, if 
the pains of the joints continue, they are less violent, more 
limited in their place, being confined commonly to one or 
a few joints only, and are less ready to change their place. 

449.] When the pyrexia attending rheumatism has en- 
tirely ceased ; when the swelling, and particularly the red- 
ness of the joints, are entirely gone ; but when pains still 
continue to affect certain joints, which remain stiff, which 
feel uneasy upon motion, or upon changes of weather ; the 
disease is named the Chronic Rheumatism, as it very often 
continues for a long time. As the chronic is commonly the 
sequel of the acute rheumatism, I think it proper to treat of 
the former also in this place. 

450.] The limits between the acute and chronic rheuma- 
tism are not always exactly marked. 

When the pains are still ready to shift their place ; when 
they are especially severe in the night-time ; when, at the 
same time, they are attended with some degree of pyrexia, 
and with some swelling, and especially with some redness 
of the joints; the disease is to be considered as still partak- 
ing the nature of the acute rheumatism. 

But when there is no degree of pyrexia remaining ; when 
the pained joints are without redness; when they are cold 
and stiff; when they cannot easily be made to sweat; or 
when while a free and warm sweat is brought out on t 
of the body, it is only clammy and cold on the pained 

X 



I5S PRACTICE OF PHYSIC. 

joints; and when, especially the pains of these joints are 
increased by cold, and relieved by heat applied to them; 
the case is to be considered as that of a purely chronic 
rheumatism. 

451.] The chronic rheumatism may affect different joints; 
but is especially ready to affect those joints which are sur- 
rounded with many muscles, and those of which the mus- 
cles are employed in the most constant and vigorous exer- 
tions. Such is the case of the vertebrae of the loins, the 
affection of which is named Lumbago ; or that of the hip- 
joint, when the disease is named Ischias, or Sciatica. 

452.] Violent strains and spasms occurring on sudden 
and somewhat violent exertions, bring on rheumatic affec- 
tions, which at first partake of the acute, but very soon 
change into the nature of the chronic rheumatism. 

453.] I have thus delivered the history of rheumatism ; 
and suppose, that, from what has been said, the remote 
causes, the diagnosis, and prognosis of the disease, may 
be understood. The distinction of the rheumatic pains 
from those resembling them, which occur in the syphilis 
and scurvy, Avill be obvious, either from the seat of those 
pains, or from the concomitant symptoms peculiar to these 
diseases.* The distinctions of rheumatism from gout will 
be more fully understood from what is to be delivered in 
the following chapter. 

454.] With respect to the proximate cause of rheuma- 
tism, there have been various opinions. It has been impu- 
ted to a peculiar acrimony; of which, however, in or- 
dinary cases I can find no evidence; and from the consi- 
deration of the remote causes, the symptoms and cure of 
the disease, I think the supposition very improbable. 

The cause of an Ischias Nervosa assinged by Cotunnius, 
appears to me hypothetical, and is not supported by either 
the phenomena or method of cure. That, however, a dis- 
ease of a rheumatic nature may be occasioned by an acrid 
matter applied to the nerves, is evident from the tooth-ach, 
a rheumatic affection generally arisingfroma carious tooth. 

That pains resembling those of rheumatism may arise 
from deep seated suppurations, we known from some ca- 

* To distinguish the chronic rheumatism from venereal or scorbutic pains, is, however, in 
some cues, extremely difficult, and often requires the utmost sagacity of the practitioner. A 
clue attention to the causes of rheumatism, recited in the foregoing articles, and a strict exami- 
nation whether the paii'tit has been subjected to these causes, will sometimes determine the 
disease ; but it often Happens, that the same causes which produce rheumatism, also exacerbate 
venereal ind scorbutic pains. No general rules can be delivered on this subject ; andtheprar- 
roust trust to his own sagacity for direction in tl»is difficult diagnosis. 



PRACTICE OF PHYSIC. 159 

scs depending on such a cause, and which, in their symp- 
toms, resemble the lumbago or ischias. I believe, how- 
ever, that by a proper attention, these cases depending on 
suppuration, may be commonly distinguished from the 
genuine cases of lumbago and ischias; and, from what is 
said in (447.) I judge it to be at least improbable, that a 
genuine lumbago or ischias does ever end in suppuration. 

455.] The proximate cause of rheumatism has been by 
many supposed to be a lentor of the fluids obstructing the 
vessels of the part; but the same consideration as in (241. 
1, 2, a, 4, and 5.) will apply equally here for rejecting the 
supposition of a lentor. 

456.] While I cannot, therefore, rind either evidence 
or reason for supposing that the rheumatism depends upon 
any change in the state of the fluids, I must conclude, that 
the proximate cause of acute rheumatism, is commonly 
the same with that of other inflammations not depending 
upon a direct stimulus. 

457.] In the case of rheumatism, I suppose, that the most 
common remote cause of it, that is, cold applied, ope- 
rates especially on the vessels of the joints, from these be- 
ing less covered by a cellular texture than those of the in- 
termediate parts of the limbs. I suppose further, that the 
application of cold produces a constriction of the extreme 
vessels on the surface, and at the same time an increase of 
tone or phlogistic diathesis in the course of them, from 
which arises an increased impetus of the blood, and, at 
the same time, a resistance to the free passage of it, and 
consequently inflammation and pain. Further, 1 suppose, 
that the resistance formed excites the vis medicatrix to a 
further increase of the impetus of the blood; and, to sup- 
port this, a cold stage arises, a spasm is formed, and a 
pyrexia and phlogistic diathesis are produced in the whole 
system. 

458.] According to this explanation, the cause of acute 
rheumatism appears to be exactly analogous to that of the 
inflammations depending on an increased afflux of blood 
to a part while it is exposed to the action of cold. 

15ut there seems to be also, in the case of rheumatism, a 
peculiar affection of the fibres of the muscles. 

These fibres seem to be under some degree of rigidity, 
and therefore less easily admit of motion ; and are pained 
upon the exertions of it. 

It is also an affection of these fibres which gives an op- 



160 PRACTICE OF PHYSIC. 

portunity to the propagation of pains from one joint to 
another, along the course of the muscles, and which pains 
are more severely felt in the extremities of the muscles ter- 
minating in the joints, because, beyond these, the oscil- 
lations are not propagated. 

This affection of the muscular fibres attending rheuma- 
tism, seems to explain why strains and spasms produce 
rheumatic affections ; and, upon the whole, shows, that, 
with an inflammatory affection of the sanguiferous system, 
there is also in rheumatism a peculiar affection of the mus- 
cular fibres, which has a considerable share in producing 
the phenomena of the disease. 

459.] Having thus given my opinion of the proximate 
cause of rheumatism, I proceed to treat of the cure. 

460.] Whatever difficulty may occur with respect to the 
explanation given, (457. and 458.) this remains certain, 
that in acute rheumatism, at least in all those cases which 
do not arise from direct stimuli, there is an inflammatory 
affection of the parts, and a phlogistic diathesis in the whole 
system; and upon these is founded the method of cure, 
which frequent experience has approved of. 

461.] The cure therefore requires, in the first place, an 
antiphlogistic regimen, and particularly a total abstinence 
from animal food, and from all fermented or spirituous li- 
quors ; substituting a vegetable or milk diet, and the plen- 
tiful use of bland diluent drinks. 

462.] Upon the same principle (449.) at least with per- 
haps the same exception as above, blood-letting is the chief 
remedy of acute rheumatism. The blood ought to be 
drawn in large quantity, and the bleeding is to be repeated 
in proportion to the frequency, fullness, and hardness of 
the pulse, and to the violence of the pain. For the most 
part, large and repeated bleedings, during the first days 
of the disease, seem to be necessary, and accordingly have 
been very much employed: but to this some bounds are 
to be set ; for very profuse bleedings occasion a slow re- 
covery, and, if not absolutely effectual, are ready to pro- 
duce a chronic rheumatism. 

463.] To avoid that debility of the system, which ge- 
neral bleedings are ready to occasion, the urgent symptom 
of pain ma}' be often relieved by topical bleedings ; and 
especially when any swelling and redness have come upon 
a joint, the pain of it may be very certainly relieved by 
such bleedings ; but, as the continuance of the disease 



PRACTICE OF PHYSIC. J61 

seems to depend more upon the phlogistic diathesis of the 
whole system, than upon the affection of particular parts, 
so topical bleedings will not always supply the place of the 
general bleedings proposed above.* 

464.] To take off the phlogistic diathesis prevailing in 
this disease, purging may be useful, if procured by medi- 
cines which do not stimulate the whole system, such as the 
neutral salts, and which have, in some measure, a refrigerant 
power. f Purging, however, is not so powerful as bleeding, 
in removing phlogistic diathesis ; and when the disease has 
become general and violent, frequent stools are inconveni- 
ent and even hurtful, by the motion and pain which they 
occasion. 

465.] In acute rheumatism, applications to the pained 
parts are of little service. Fomentations, in the beginning 
of the disease rather aggravate, than relieve the pains. The 
rubefacients and camphire are more effectual in relieving the 
pains ; but generally they only shift the pain from one part 
into another, and do little towards the cure of the general af- 
fection. Blistering, applied to the pained part, may also be 
very effectual in removing the pain from it; but will be of 
little use, except where the pains are much confined to 
one part. 

466.] The several remedies mentioned from (450. to 454.) 
moderate the violence of the disease, and sometimes remove 
it entirely ; but they sometimes fail in this, and leave the 
cure imperfect. The attempting a cure by large and re- 
peated bleedings, is attended with many inconveniences, 
(see 140.) and the most effectual and safe method of curing 
this disease, is, after some general bleedings for taking of], 

* These topical bleedings, however, have by repeated experience been found of essential 
advantage, especially when the partial inflammation has been very violent. They are best per- 
v leeches, many of which ought to be applied at once all over the inflamed part. Cup- 
ping has long been the favorile practice of many physicians, but it generally irritates more than 
the leeches; yet in cases, that require immediate relief, it is preferable to them. 

+ The Glauber, or Epsom salts, are the most convenient purges in all cases of acute rheuma- 
tism. Either of them may be given separately, or joined with the intusum senna;, as in the fol- 
lowing tormula : 

R. Infus. Sennse, ?iii. 
Sal. Glauber. gfj>. 
Tinct. Jalap. 3i. 
Tinct. Aromat. 3fe 
M. f. haust. 

The more suddenly purges operate in acute rheumatisms, the more efficacious are they 

. and as lar^e diluting warm thin liquors considerably accelerate the operation 

.it .ill purges, such practice IS never to be neglected in these cases. Cream of tartar wbe\, 

mixed wuh twice its quantity of warm water, is a very proper drink to assist the operation of 

purees. 



169 PRACTICE OF PHYSIC. 

or at least diminishing, the phlogistic diathesis, to employ 
sweating, conducted by the rules laid down (168. and 169.)* 

467.] Opiates, except where they are directed to pro- 
cure sweat, always prove hurtful in every stage of this dis- 
ease, f 

468.] The Peruvian bark has been supposed a remedy 
in some cases of this disease ; but we have seldom found 
it useful, and in some cases hurtful. It appears to me to 
be fit in those cases only, in which the phlogistic diathesis 
is already much abated, and where, at the same time, the 
exacerbations of the disease are manifestly periodical, with 
considerable remissions interposed.^ 

469.] Calomel and some other preparations of mercury, 
have been recommended in the acute rheumatism ; but I 
believe they are useful only in cases of the chronic kind, 
or at least in cases approaching to the nature of those. 

470.] Having now treated fully of the cure of the acute 
rheumatism, I proceed to treat of the cure of the chronic, 
which is so frequently a sequel of the former. 

471.] The phenomena of the purely chronic rheumatism, 
mentioned in (438. and 439.) lead me to conclude, that its 
proximate cause is an atony, both of the blood-vessels and 
of the muscular fibres of the part affected, together with a 
degree of rigidity and contraction in the latter, such as fre- 
quently attends them in a state of atony. 

472.] Upon this view of the proximate cause the gene- 
ral indication of cure must be, to restore the activity and 
vigor of the vital principle in the part ; and the remedies 
for this disease, which experience has approved of, are chief- 
ly such as are manifestly suited to the indication proposed. 

473.] These remedies are either external or internal. 

* Sweating is most effectual in this disease, when produced by Dover's powder. The dose of 
it is twelve or fifteen grains, repeated at intervals, of two or three hours, till a sweat be pro- 
duced. Diluent drinks are to be used with it: and it may be necessary to observe, that they 
ought to be such as are bland, and by no means stimulating; viz. barley-water, lmtseed-tea' r 
thin water-grueli &c. 

+ Notwithstanding this caution, many practitioners use opiates, especially when joined with 
camphor, to procure sweats in acute rheumatism. This compound never fails to increase the 
phlogistic diathesis, and consequently must be hurtful. In the chronic rheumatism, indeed, 
•Kinpnor and opium together form a valuable medicine. The dose is the following bolus : 

R. Camphor, gr. vi. 
Sp. Vini, gutt. x. 
Opii, gr. i. 
Tart. Vitriol, gr. xv. 
Syr. q. s. M. f. bolus. 

t Bark is always an ambiguous remedy in rheumatism, and on its first introduction into prac- 
tice u was thought to occasion or induce the disease. Wherever an inflammatory diathesis pre- 
vails, the Peruvian bark is always an improper medicine, and it has been found by ex peril 
to be manifesifv hurttul in the beginning-) or inflammator; state of rheumatism. 



PRACTICE OF PHYSIC. 156 

The external are, the supporting the heat of the part, by- 
keeping it constantly covered with flannel ; the increasing 
the heat of the part by external heat, applied either in a dry 
or in a humid form ; the diligent use of the flesh-brush, or 
other means of friction ; the application of electricity in 
sparks or shocks ; the application of cold* water by affu- 
sion or immersion ; the application of essential oils of the 
most warm and penetrating kind ; the application of salt 
brine ; and, lastly, the employment of exercise, either of 
the part itself so far as it can easily bear it, or of the whole 
body by riding or other mode of gestation. 

474.] The internal remedies are, 1 . Large doses of es- 
sential oil drawn from resinous substances, such as turpen- 
tine ;f 2. Substances containing such oils, as guaiac ;J 3. 
Volatile alkaline salts ; 4. These, or other medicines di- 
rected to procure sweat, (169.) and, lastly, Calomel, |j or 
other preparation of mercury, in small doses, continued 
for some time. 

475.] These (462, 463.) are the remedies successfully 
employed in the purely chronic rheumatism ; and there are 
still others recommended. As bleeding, general and to- 
pical, burning, blistering, and issues: but these appear to 
me to be chiefly, perhaps only, useful when the disease still 
partakes of the nature of acute rheumatism.^ 

* Thi«, when compared with article 457, and others, seems to be a typographical error, and 
the autlior meant warm. Practice affords many instances of chronic rheumatisms being occa- 
sioned by cold bathing. 

+ Turpentine is an extremely heating oil, as indeed are all the essential oils : its use there- 
fore requires the greatest caution. The dose is from eight to fifteen drops on a piece of sugar. 
Venice turpentine may be more conveniently given in the form of an emulsion, by dissolving it m 
water by means of yolks of eggs. Two scruples of turpentine is the ordinary dose ; and when 
given in this liquid and diluted state, is much preferable to the oil. 

t The officinal preparations of guaiacum, are an extract of the wood, a solution of the gum 

m rectified spirit, another in volatile alkali, and an empyreuniatical oil. The gum may be 

(jiven in the quantity of fifteen or twenty grains for a dose, eiiher in a bolus, or made into an 

emulsion with yolk of egg and an ounce or two of water : in larger quantities it is too purgative. 

. olatile elixir of the Edinburgh Pharmacopoeia is an excellent torm, as the volatile spirit 

promotes the medicinal virtue of the guaiacum The dose of it is from a drachm to hall an ounce, 

morning and evening, in any convenient vehicle ; a tea cupful of milk is the best as it sheaths, 

in some measure the pungency of the medicine. Guaiacum is very conveniently joined with 

rhubarb and magnesia, when we find that such a dose of it, as is necessary for procuiing a sut- 

il opening, v/ould be too heating. A formula of this kind is described in the note on arti- 

I. 

llomel, perhaps, has only been serviceable in venereal cases. 

$ i'he diet in the cure of chronic rheumatism ought to be generous and full. In ruanv cases, 

tally among people in poor cucumstances, good living, with two or three glasses of sherry 

in the day, has cured the disease without any medicines. One material circumstance ought not 

omitted ; viz. that the cure is much impeded by costiveness : if, therefore, the guaiacum 

not procure two motions in the day, it will be necessary to give along with it some warm 

rive. The tinctura sacra is a proper medicine in these cases: its dose is from one to two 

oun the elixir sacrum of the Edinburgh College Pharmacopoeia, its dose may b» 

dratihm to half an ounce, as occasion may require. 



164 PRACTICE OF PHYSIC. 



CHAPTER XIII. 

OF THE TOOTHACH, OR ODONTALGIA. 

476.] T HAVE formerly considered this disease as aspe- 
A cies of Rheumatism, to be treated upon the same 
principles as those delivered in the preceding chapter : but now 
from more attentive consideration, I am led to consider the 
toothach as a distinct disease. Whilst the most of what has 
been delivered in the last chapter proceeds upon the sup- 
position that the rheumatism depends upon a certain state 
of the blood vessels and of the motion of the blood in them, 
without this being produced by the irritation of any acrid 
matter applied ; I judge, that in the toothach, though there 
are often the same circumstances in the state of the blood- 
vessels as in the cases of rheumatism, these circumstances 
in toothach always arise from the application of an acrid 
matter to the nerves of the teeth. 

477.] This disease is often no other than a pain felt in a 
particular tooth, without any inflammatory affection being 
at the same time communicated to the neighboring parts* 
This, however, is rarely the case ; and for the most part to- 
gether with the pain of the tooth, there is some degree of 
pain and of inflammatory affection communicated to the 
neighboring parts, sometimes to the whole of those on the 
same side of the head with the affected tooth. 

473.] This inflammatory affection seems to me to be al- 
ways an affection of the muscles and of the membranous 
parts connected with these, without any tendency to sup- 
puration ; and such an affection, as is excited by cold in 
similar parts elsewhere. It is from these circumstances that 
I conclude the affection to be of the rheumatic kind. 

479.] It is possible that the muscles and membranes of 
the jaw may be affected by the same causes which produce 
the rheumatism in other parts ; and it is also possible, that 
a rheumatic diathesis at first produced bv irritation, may 
subsist in the muscles and membranes of the jaw, so that 
the inflammatory affection may be renewed by certain 
causes without any new application of acrid matter : But 
I am persuaded that either of these occurrences are very 
rare, and I have never been able to ascertain any cases of 



PRACTICE OF PHYSIC. 165 

toothach to be of these kinds. I consider it, therefore, 
as highly probable that this rheumatic affection of the jaws 
which Ave name toothach, is always dependent upon some 
immediate application of acrid matter to the nerves of the 
teeth. 

480.] It is however to be observed, that this application 
of acrid matter does not always excite a pain in the tooth 
itself, or an inflammatory affection of the neighboring 
parts ; but that it very often operates by producing a dia- 
thesis only ; so that cold applied to the neighboring parts 
does excite both a pain in the tooth, and an inflammatory 
affection of the neighboring parts which did not appear 
before. 

There seems to be also certain states of the body, which 
operate upon the same diathesis so as to produce toothach. 
Such seems to be the case of pregnant women, who are 
more liable to toothach than other women. There are 
probably also some cases of increased irritability which 
render persons more subject to toothach. Thus women 
are more liable to the disease than men, and particularly 
women liable to hysteric affections. 

481.] The acrid matter producing this disease seems to 
be generated first in the hard substances of the teeth; and 
as it often appears first upon the external surface of these, 
it might be suspected to arise from the application of exter- 
nal matters to the teeth: But as the production of this 
acrimony is often begun in the internal cavity of the teeth, 
where the operation of external matters cannot be suspect- 
ed, and as even when it begins upon the external parts of 
the teeth, the operation of the cause is at first in a small 
portion of the teeth only, that it is difficult to suppose that 
any matter externally applied could act in such a partial 
manner; so it is presumed that the acrid matter occasion- 
ing the toothach is produced by some vice originating in 
the substance of the tooth itself. When it begins upon the 
external surface, it is on the enamel; but upon the inter- 
nal surface, it must be in the bony part. From what caus- 
es it arises in either of these substances, I do not at all 
know ; but I suspect that it often arises from some more 
general fault in the fluids of the body. The frequent use 
of mercury, especially when thrown much upon the mouth, 
and the state of the fluids in scurvy, seem both of them to 
give a disposition to a caries in the teeth ; and it is possi- 



160 PRACTICE OF PHYSIC. 

ble that some other acrimonious states of the fluids msy 
have the same effect. 

482.] A caries in some part of the teeth, whether aris- 
ing upon their internal surface or upon their external, 
proceeding so far as to reach the nerves in the cavity of 
the teeth, is pretty manifestly the cause of toothach, and 
of the first attacks of it ; but when the cavity of the teeth 
has been opened, so that the external air or other matters 
can reach that cavity, these are often the exciting causes 
of toothach, and serve to prove in general, that acrid 
matters applied to the nerves occasion the disease. 

483.] What is the nature of the matter produced in the 
caries of the teeth, I do not understand, nor have I found 
any proper corrector of it ; but 1 presume it to be of the 
putrid kind, as it often taints the breath with a fetid odour. 

484.} In the cure of this disease, a long experience has 
shown, that the extraction of the carious tooth proves the 
most effectual, and very often the only effectual, remedy 
of the disease. But as in some cases this extraction is not 
proper, and as in many cases it is obstinately avoided, 
other means of curing the disease, or at least of relieving 
the pain have been sought for and much practised. 

485.] Among these remedies, those are likely to be the 
most effectual which entirely destroy the affected nerve, or 
at least so much of it as is exposed to the action of the acrid 
matter in the tooth. When an opening is made into the 
cavity of the tooth, the nerve of it may be destroyed most 
certainly by the actual cautery; and it may also possibly 
be done by the application of potential caustics, either of 
the alkaline or acid kind. 

486.] When these remedies cannot be rendered effectu- 
al, relief may often be obtained by diminishing the sensi- 
bility of the nerve affected, by the application of opium, 
or of the more acrid aromatic oils,"* and directly to the 
nerve in the tooth. It appears also, that the sensibility of 
the affected nerve may often be for some time diminished 
by the external application of opium to the extremities of 
those nerves in the skin, which are branches of the same 
fifth pair of nerves with those of the teeth. 

437.] When the disease consists entirely in a pain of the 
nerve of the tooth, without any considerable affection com- 
municated to the neighboring parts, the remedies already 

* The Oleum Ori^ani is the oil generally used fur this purpose. Great care must be taken in 
■sing either these acrid essential oils, or the vitriolic or other mineral acids, that no part of tl.eia 
touch the sums. 



PRACTICE OF PHYSIC. 167 

mentioned are those especially to be employed ; but when 
the disease consists very much in an inflammatory affec- 
tion of the muscles and membranes of the jaw, and when 
at the same time there is little or no access for the above- 
mentioned remedies to the affected nerve, other measures 
are to be employed for relieving the disease. 

488.] If the disease be attended with any general phlo- 
gistic diathesis of the system, or with any considerable de- 
gree of pyrexia, a general bleeding may be useful in re- 
lieving the disease : but these circumstances occur very 
rarely, and the disease is for the most part a purely topical 
affection ; in which, as I observed before, a general bleed- 
ing is of very little service. As this disease, however, is a 
topical inflammation, it might be supposed that topical 
bleedings would be very useful, and sometimes they are 
50; but it is seldom that their effects are either considera- 
ble or permanent. The reasons of this I take to be that 
the disease does not consist in an affection of the blood- 
vessels alone, as in the ordinary cases of rheumatism ; but 
in a peculiar affection of the fibres both of the muscles and 
of the vessels of the part induced by irritation. The inef- 
ficacy of topical bleedings is with me a proof of the disease 
being of the latter kind. 

489.] The remedies therefore necessary to give relief in 
this disease, are those which take off the spasm of the ves- 
sels, and especially of the muscles and membranes affect- 
ed. Such are blistering, brought as near to the part affect- 
ed as can be conveniently done ;* and such are also increas- 
ed excretions excited in the neighboring parts, as of the 
saliva and mucus of the mouth by the use of acrid masti- 
catoriesf It is often sufficient to excite a strong sensation 

* Blisters are applied most successfully behind the cars. Such applications however are al- 
ublesome; and their effects are often doubtful. Other milder stimulant* frequently 
answer all the intentions of blisters, and by many practitioners are thought to be equally eltica"- 
cious. The applications generally used aie camphorated spirit, or volatile a, Lab. This last 
either alone, or raized with an equal quantity of oil of almonds, rubbed on the jaw, Uie part 
heing kept warm by a piece of flannel, has ofted been found extremely useful 

Warmth, anyhow produced on the part, ::lways gives relief j while, on the contrary, cold 
alwaysj eatasperates the symptoms: hence the propriety of covering the jaws wnh flannel, 
and avoiding a cold stream of air. 

+ The*. Ilsh, scurvy-grass, the greater celandine, with some others: but the ra- 

dix pyrethn is the best. In some pharmacopoeia, but 1 do not recollect winch, there is a for- 
■lula, called Trochisci Sialagogi, to the best of mv remembrance, as follows : 

R. Pulv. Rad. Pyrethri, l'u 
Gum. Mastich. B f j> 
Ol. Caryopyhll. Aromat. 
Ol. Marjoranae, 55 Ji. 
Ceras Alb. q. s. ut. f. Trochisci. 

these held in the mouth, or chewed, promotes a copious etischaree of saliva, by 
warming and stimulating the salivary glands. 



16$ PRACTICE OF PHYSIC. 

in the neighboring parts ; as by eau de luce, spirit of laven- 
der, or Hungary water snuffed up the nostrils ; or by the 
vitriolic aether properly applied to the cheek. It is upon 
the same footing that I suppose brandy or other ardent spi- 
rit held in the mouth is often of service. 

490.] There are cases of toothach in which it does not 
appear that the disease arises from an acrid matter imme- 
diately applied to the nerve of a tooth ; but from the ex- 
ternal application of cold, or some other causes immedi- 
ately applied to the muscles and membranes of the jaw ; 
and which therefore seem to require some remedies differ- 
ent from those above mentioned. But in all such cases, 
it is to be suspected, that the effects of cold or of other 
such causes are owing to a diathesis produced by an acrid 
matter applied to the nerve of a tooth, and continuing 
in some measure to act there ; and we have according- 
ly often found, that the action of those external causes 
were to be obviated only by the extraction of the tooth 
from which the diathesis had arisen. 



CHAPTER XIV. 
OF THE GOUT. 

491.] 'THHE Gout, not only as it occurs in different per- 
JL sons, but even as it occurs in the same person 
at different times, is a disease of such various appearance, 
that it is difficult to render the history of it complete and 
exact, or to give a character of it that will universally ap- 
ply. However, I shall endeavor to describe the disease as 
it most commonly appears, and to mark the varieties of it 
as well as I can. From such a history I expect that a ge- 
neral character may be given ; and such I think is the fol- 
lowing, as given in the last edition of our Nosology : 

Gen. XXIII. PODAGRA. Morbus hasreditarius, ori- 
ens sine causa externa evidente, sed praseunte plerumque 
ventriculi affectione insolita; pyrexia; dolor ad articulum 
et plerumque pedis pollici, certe pedum et manuum junc- 
turis, potissimum infestus ; per intervalla revertens, et 
saepe cum ventriculi et internarum partium affectionibus 
alternans. 

492.] The Gout is generally a hereditary disease : but 



PRACTICE OF PHYSIC. 169 

some persons, without hereditary disposition, seem to ac- 
quire it ; and, in some a hereditary disposition may be 
counteracted by various causes. These circumstances 
may seem to give exceptions to our general position j but 
the facts directly supporting it are very numerous. 

4<J3.J This disease attacks especially the male sex : but 
it sometimes, though more rarely, attacks also the female.* 

* Hippocrates says, that women seldom have the gout, and never before the disappearance 
•f the catamenia. In his time and country, perhaps, the ladies were more temperate tli3n 
they were in other ages and in other places. We rind the zoi't a familiar disease among the 
Roman ladies ; which Seneca, in his ninety fifth epistle, justly ascribes to the luxurious Irving 
and debaucheries, in which they indulged without control. 

As the whoie a of that epistle is .in excellent account of t'ne direful effect; of high living and. 
debauchery, it may not be unacceptable to the young practitioner, who, perhaps, might other- 
wise be unacquainted with so just a description of luxurous living, and its concomitant evils. 
Independent ol us containing a minute relation of Roman customs, which makes it a valuable 
morsel tor antiquaries, it may be read with peculiar advantage by the young physician. 

As an apology for giving it In the original, I shall say of Seneca what an elegant English writer 
says of Cicero: That any translation of his nervous language) is like the faint glimmerings of a 
taper compared with the blazing light of the meridian sun. 

" Medicina quondam paucaruin fuit scientia heibarum, quibus sisteretur sanguis fluens, vul- 
nera coterent paulatira. Deinde in banc pervenit !am multipliccm varietatem. Nee mi- 
rum est ; tunc illam minus negotii habuisse, nrmis adhunc, tolidisque corpoiibus, et facili cibo, 
nee perartem voiuplatemque conupto. Qui postquam cepit, non ad tollendam, sed ad irri- 
tandamfamen quxri, et invents sunt mille condirura?, quibus aviditas excitaretur : qui de- 
siderantibus aliinenta erant, onera sunt plenis. Inde pallor, et nervorum vino madentium tre- 
mor, et mi*trabilior ex cruditaubus quain ex fame macies. Inde incerti labentium pedes, et 
temper qualis in ipsa ebrietate titubatio. Inde in totam cutem humor admissus, distcntusquc 
venter, iluni male assuescit )ilus capere, quain poterat. Inde suflusio luridx bilis, et decolor, 
vultus, tabesque in se putrescentium, et retorti digiti articulis obrigescentibus, nervorum sine 
sensu jacentiura, torpor autpalpitatio sine intermissione vibrantium. Quid capitis vertigines 
dicain ! Quid oculorum aunumque tonnenta, et cerebri xstuantis verminationes, et omnia 
perquzexoneramur intern is ulceribus affecta? Innumerabilia prxterea febnum genera, alia- 
rum unpetu subeuntium, aharuru tenui peste repentiuin, aliamm cum horroreet multa inem- 
brorum quassatione venicntiuin? Quid alios referam innumerabiles morbos, supplicia luxurix ? 
Iminunes erant ab istis inalijqui nondum sc deliciis solverant, qui sibi impcrabant, sibi minis- 
trabant. Corpora opere ac vero labore durabant, aut cursu defatigati, aut venatu, ant telluie 
versata. Excipiebat pilot cibus qui nisi esurientibus placere non poterat. ltaque nihil opug 
erat tain magna medicorum supellectile. nee tot ferramentis atque pyxidibus. Simplex erat ex 
litnplice causa valetudo. Multos morbos multa fercula fecerunl, Vide quantum rerun) per 
unam gulam trarjttturarum permisceat luxuria, ten-arum marisque vastatrix. Necesse est itaque 
inter se tain diveisa dissideant, et hausta mali digerantui, alns alio nitentibus. Nee mirum, 
quod inconstans variusque ex discordi cibo morbus est, et ilia ex eontrariis naturx partibus in 
eundem compulsa ledundant. Inde tarn nullo a\grotamus genere quam vivimus. Maximus 
ille medicorum, ethujus scientix conditor, feminis nee capillos defluerc dixit, nee pedes labo- 
rare. Atquihx jam et capillis distituuntur, et pedibus xgrx sunt. Non mutata feminarum 
natura, sed vita est. Nam cum virorum licentiam xquavci int, eorporum quoque virilium vitia 
Muavenint. Non minus pervigilant, non minus pOCBiit, et olco et mero virus provueant. 
Aque invitis ingesta visceribus per os reddunt, et vinum omne voinitu remetiuntur ; xque 
nlvetn rodunt, solatium stomachi xsluantis. Libidini vero nee maribus quidem cedunt, pati 
iiau. Du Idas deaque male perdant: adeo perversum commentx genus impudicmx vuos 
i iicu ni Quid ergo mirandurn est, maximum medicorum ac naturx pertissimum, in mendacio 
prehendi, cum tot feminx podagricx calvxque sint. Benefieium sexus sui vitiis perdiderunt ; 
ct quia fcminamexuerunt, damnatx sunt morbis virilibus. Antiqui medici nesciebant dare ci- 
btim sxpius, et vino fulcin venas cadentes ; nesciebant saniem emittere, et diutinam xgrota- 
tumem balneo sudonbusque laxate ; nesciebant cm rum vinculo, bracluoiumque, lateniem 
vim, et in medio sedentcm, ad extrema revoe.tie. Non erat necesse circumspicere multa auxi- 
liorum genera cum essenl periculomm paucissima. Nunc autem quam longe processerunt 
tudinis? lias usuras volupta turn penditn us, ultra modum lasiiuc concupitarum. In- 
■umerabiles esse morbus miraris! Coquos numera. Cessat omne studium ; et liberalia professi, 
sine ulla frequentia, desertis angulis , In rhetorum ac philosopnorum scholis solitudo 

est. Ai quam cclebres cuiinxsunt » Quanta nepotuin tocos juventus premitr Transeo puero- 
rum Infelicium greges; quoi post transacta convivia alia' cubiculi contumclix expectant. Tran- 

i per nationes coloretque descripta, et eadem omnibus levitas sit, 
pi iii.i mensura lanuginis, eadem species capillorum, ne quiscui rectior sit coma, crispuiis misce- 
atur. Transeo pistorum turbam, transeo ministraiomm, per quos signo dato ad inferenoam 
discurritur. Un boni quantum hominum onus venter exercet 1 Quid tu illos boletus, 
voluptarhim venenum, nihil oculti operis judicas facere, etiamsi prxsentanei non furant; Rmd 
tu illam xstivam nivem non putai callum jecinoribus obducere i Quid ilia ostrea, inertissimani 
carnem, ccno saginatam, nihil existimas limusx gravitatis inferre I Quid illud sociorum garum, 
i piscium samem, non credit urere salsa tabe prcecordia ! Quid ilia puruk-nta, et quae 
l.iniuin non ab ipso igne in os transfer untur, judicas, sine noxa, in ipsis visceribus extinguii 
Quam leedi atque pestilentcsruclus sunt, quantum fasiidium sui, exhalantibus crapubm vcte- 
jemf" 



170 PRACTICE OF PHYSIC. 

The females liable to it are those of the more robust 
and full habits ; and it very often happens to such long be- 
fore the menstrual evacuation has ceased. I have found it 
occurring in several females, whose menstrual evacuations 
were more abundant than usual. 

494.] This disease seldom attacks eunuchs, and when it 
does, they seem to be those who happen to be of a robust 
habit, to lead an indolent life, and to live very full. 

495.] The gout attacks especially men of robust and 
large bodies, men of large heads, of full and corpulent ha- 
bits, and men whose skins are covered with a thicker rete 
mucosum, which gives a coarser surface. 

496.] If with the ancients, we might ascertain, by cer- 
tain terms, the temperaments of men, I would say, that 
the gout attacks especially men of a cholerico-sanguine tem- 
perament, and that it very seldom attacks the purely san- 
guine or melancholic. It is however, very difficult to treat 
this matter with due precision. 

497.] The gout seldom attacks persons employed in con- 
stant bodily labor, or persons who live much upon vege- 
table aliment. It is also said to be less frequent among 
those people who make no use of wine or other fermented 
liquors. 

498.] The gout does not commonly attack men, till af- 
ter the age of five and thirty ; and generally not till a still 
later period. There are indeed instances of the gout oc- 
curring more early ; but these are few in comparison of the 
numbers which agree with what we have given as the ge- 
neral rule. When the disease does appear early in life, it 
seems to be in those in whom the hereditary disposition is 
very strong, and to whom the remote causes to be hereafter 
mentioned have been applied in a considerable degree. 

499.] As the gout is a hereditary disease, and affects es- 
pecially men of a particular habit, its remote causes may 
be considered as predisponent and occasional. 

500.] The predisponent cause, so far as expressed by 
external appearances or by the general temperament, we 
have already marked ; and physicians have been very con- 
fident in assigning the occasional causes : but, in a disease 
depending so much upon a predisposition, the assigning 
occasional causes must be uncertain ; as in the predisposed, 
the occasional causes may not always appear, and in per- 
sons not predisposed, they may appear without effect. 
This uncertainty must particularly affect the case of the 



PRACTICE OF PHYSIC. n% 

gout ; but I shall offer what appears to me most probable 
on the subject. 

501.] The occasional causes of the gout seem to be of 
two kinds. First, those which induce a plethoric state of 
the body. Secondly, those which in plethoric habits, in- 
duce a state of debility. 

502.] Of the first kind are a sedentary indolent manner 
of life, a full diet of animal food, and the large use of wine 
or of other fermented liquors. These circumstances com - 
monly precede the disease ; and if there should be any 
doubt of their power of producing it, the fact, however, 
will be rendered sufficiently probable by what has been 
observed in (497.) 

503.] Of the second kind of occasional causes which 
induce debility are, excess in venery ;* intemperance in. 
the use of intoxicating liquors ;f indigestion, 'produced 
either by the quantity or quality of aliments ;% much ap- 
plication to study or business ; || night watching ;§ exces- 
sive evacuations ;** the ceasing of usual labor ;ff the sud- 
den change from a very full to a very spare diet ;%% the 
large use of acids and acescents ;|||| and, lastly, cold§§ ap- 
plied to the lower extremities. 

504.] The first (502.) seem to act by increasing the pre- 
disposition. The last (503.) are commonly the exciting 
causes, both of the first attacks, and of the repetitions of 
the disease. 

* Why excess of venery should be a cause of gout, has much engaged the attention of medi- 
cal writers, and various reasons have been given why it should produce such an effect. There 
is not the least doubt of the fact, though some authors have ventured to deny it, and have ex- 
cluded the excess of venery from being a cause of gout. 

It produces gout not primarily, but secondarily, it 1 may be allowed the expression, by induc- 
ing a general state of debility, and by weakening the power of digestion, both of which cir- 
cumstances are causes of the gout. 

+ By intemperate drinking the action of the stomach and bowels becomes extremely feeble 
and languid) if it be not wholly destroyed ; hence continual indigestions, to which the origin 
of the gout is attributed. 

t Both the quantity and quality of the aliments may produce indigestion : and hence the in- 
dulging in too great a quantity of aliment, as well as in that which is of an indigestable nature, 
arc secondary causes of the gout ; viz. causes which induce a state of debility. 

II Much application to study may doubtless induce indigestion, and thus increase the genera J 
state of debility: it is not, however, by intense study, or deep thinking merely, that men grow 
pale amid their books, but by the sedentary life which studious men generally lead, and the un- 
timely lucubrations in which they inconsiderately indulge. 

application to business can onry be an occasional cause of the gout, when the business 
a sedentary and inactive life ; but as most business requires activity, attention to busi- 
n the cause of gout. 
{ The want of sleep is always a cause of indigestion, and increases debility more perhaps, whea 

, than an) other ol the circumstances mentioned by the author. 
** That large evacuations induce debilit) is sufficiently evident. 

++ Nothing mure effectually promotes digestion than proper exercise ; the leaving off accus- 
tomed labor must therefore necessarily induce indigestion and consequent debility. 
X% Why this Induces debility is evident. See note on article 548. 

ihc digestive powers of the stomach, may produce debility, is 
ractittonei alii 
H How cold thus applied, can produce a state of debility, is not very evident. It is,however, 
one oi the occasional causes of gout, as experience sufficiently testifies. 



112 PRACTICE OF PHYSIC. 

505.] It is an inflammatory affection of some of the 
joints, which especially constitutes what we call a parox- 
ysm of the gout. This sometimes comes on suddenly 
without any warning, but is generally preceded by seve- 
ral symptoms ; such as the ceasing of a ,sweatin<r -which 
the feet had been commonly affected with before ; an un- 
usual coldness of the feet and legs ; a frequent numbness 
alternating with a sense of prickling along the whole of the 
lower extremities ; frequent cramps of the muscles of the 
legs ; and an unusual turgescence of the veins. 

506.] While these symptoms take place in the lower ex- 
tremities, the whole body is affected with some degree of 
torpor and languor, and the functions of the stomach in 
particular are more or less disturbed. The appetite is di- 
minished, and flatulency, or other symptoms of indiges- 
tion, are felt. These symptoms, and those of (505.) take 
place for several days, sometimes for a week or two, be- 
fore a paroxysm comes on : but commonly, upon the day 
immediately preceding it, the appetite becomes greater 
than usual. 

507.] The circumstances of paroxysms are the follow- 
ing. They come on most commonly in the spring, and 
sooner or later according as the vernal heat succeeds sooner 
or later to the winter's cold ; and perhaps sooner or later 
also according as the body may happen to be more or less 
exposed to vicissitudes of heat and cold. 

503.] The attacks are sometimes felt first in the even- 
ing, but more commonly about two or three o'clock of the 
morning. The paroxysm begins with a pain affecting 
one foot, most commonly in the ball or first joint of the 
great toe, but sometimes in other parts of the foot. With 
the coming on of this pain, there is commonly more or less 
of a cold shivering, which, as the pain increases, gradu- 
ally ceases, and is succeeded by a hot stage of pyrexia, 
which continues for the same time with the pain itself. 
From the first attack, the pain becomes by degrees more 
violent, and continues in this state with great restlessness 
of the whole body till next midnight, after which it gradu- 
ally remits; and, after it has continued for twenty four 
hours from the commencement of the first attack, it com- 
monly ceases very entirely, and, with the coming on of a 
gentle sweat, allows the patient to fall asleep. The pa- 
tient, upon coming out of this sleep in the morning, finds 
the pained part affected with some redness and swelling, 



PRACTICE OF PHYSIC. 173 

which, after having continued for some days gradually 
abate. 

509.] When a paroxysm has thus come on, although 
the violent pain after twenty four hours be considerably 
abated, the patient is not entirely relieved from it. For 
some days he has every evening a return of more consider- 
able pain and pyrexia, and which continue with more or 
less violence till morning. After continuing in this man- 
ner for several days, the disease sometimes goes entirely 
off, no't to return till after a long interval. 

510.] When the disease, after having thus remained for 
some time in a joint ; ceases very entirely, it generally 
leaves the person in very perfect health, enjoying greater 
ease and alacrity in the functions of both body and mind, 
than he had for a long time before experienced. 

511.] At the beginning of the disease, the returns of it 
are sometimes only once in three or four years : but, after 
some time, the intervals become shorter, and the attacks 
become annual ; afterwards they come twice each year, 
and at length recur several times during the whole course of 
autumn, winter, and spring ; and as it happens that, when 
the fits are frequent, the paroxysms become also longer, so, 
in the advanced state of the disease, the patient is hardly 
ever tolerably free from it, except perhaps for two or three 
months in summer. 

5 1 2.] The progress of the disease is also marked by the 
parts which it affects. At first, it commonly affects one 
foot only ; afterwards every paroxysm affects both feet, the 
one after the other ; and, as the disease continues to recur, 
it not only affects both feet at once, but after having 
ceased in the foot which was secondly attacked, returns 
again into the foot first affected, and perhaps a second time 
also into the other. Its changes of place are not only from 
one foot to the other, but also from the feet into other 
joints, especially those of the upper and lower extremities ; 
so that there is hardly a joint of the body that is not, on 
one occasion or other, affected. It sometimes affects two 
different joints at the same time ; but more commonly it is 
severe in a single joint only, and passes successively from 
one joint to another ; so that the patient's affliction is often 
protracted for a long time. 

513.] When the disease has often returned, and the pa- 
roxysms have become very frequent, the pains are common- 
ly less violent than they were at first ; but the patient is 

z 



H4 PRACTICE OF PHYSIC. 

more affected with sickness, and the other symptoms of the. 
atonic gout, which shall be hereafter mentioned. 

514.] After the first paroxysms of the disease, the joints 
which have been affected are entirely restored to their for- 
mer suppleness and strength : but after the disease has re- 
curred very often, the joints affected do neither so sudden- 
ly nor so entirely recover their, former state, but continue 
weak and stiff ; and these effects at length proceed to such 
a degree, that the joints lose their motion altogether. 

515.] In many persons, but not in all, after the -lisease 
has frequently recurred, concretions of a chalky nature 
are formed upon the outside of the joints, and for the. most 
part immediately under the skin. The matter seems to be 
deposited at first in a fluid form, but afterwards becomes, 
dry and firm. In their dry state, these concretions are a 
friable earthy substance, very entirely soluble in acids. 
After they have been formed, they contribute, with other 
circumstances, to destroy the motion of the joint. 

516.] In most persons who have labored under the gout 
for many years, a nephritic affection comes on, and disco- 
\'ers itself by all the symptoms which usually attend calcu- 
lous concretions in the kidneys, and which we shall have 
occasion to describe in another place. All that is necessary 
to be observed here is, that the nephritic affection alternates 
with paroxysms of the gout ; and that the two affections, 
the nephritic and the gouty, are hardly ever present at the 
same time. This also may be observed, that children of 
gouty or nephritic parents, commonly inherit one or other 
of these diseases ; but whichever may have been the prin- 
cipal disease of the parent, some of the children have the 
one, and some the other. In some of them, the nephritic 
affection occurs alone, without any gout supervening ; 
and this happens to be frequently the case of the female off- 
spring of gouty parents. 

517.] In the whole of the history already given, I have 
described the most common form of the disease ; and which 
therefore, however diversified in the manner I have said, 
may be still called the regular state of the gout. Upon oc- 
casion, however, the disease assumes different appear- 
ances j* but, as I suppose the disease to depend always up- 

» These different appearances which the gout assumes, are extremely unlike the regular gout 
above described ; the young practitioner ought therefore to pay peculiar attention to them, 
ibai when lie observes them in patients, he may not think them symptoms of other diseases, ox 
even mistake therft for primary diseases. Errors of this kind are frequently commuted by Jjn»- 
r.uu practitioners, to their ow'» discredit and the danger of their patient's. lite. 



PRACTICE OF PHASIC. i7S 

tm a certain diathesis or disposition of the system ; so every 
appearance which we can perceive to depend upon that 
same disposition, I shall consider as a symptom and case of 
the gout. The principal circumstance in what we term 
the Regular Gout, is the inflammatory affection of the 
joints ; and, whatever symptoms we can perceive to be 
connected with, or to depend upon, the disposition which 
produces that inflammatory affection, but without its tak- 
ing place, or being present at the same time, we name the 
Irregular Gout. 

518.] Of such irregular gout there are three different 
states, which I name the atonic, the retrocedent, and the 
misplaced gout. 

519.] The atonic state is when the gouty diathesis pre- 
vails in the system, but, from certain causes, does not pro- 
duce the inflammatory affection of the joints. In this case, 
the morbid symptoms which appear are chiefly affections 
of the stomach ; such as, loss of appetite, indigestion, and 
its various circumstances of sickness, nausea, vomiting, 
flatulency, acrid eructations, and pains in the region of 
the stomach. These symptoms are frequently accompanied 
with pains and cramps in several parts of the trunk, and 
the upperl extremities of the body, which are relieved 
by the discharge of wind from the stomach. Together 
with these affections of the stomach, there commonly oc- 
curs a costiveness ; but sometimes a looseness with cholic 
pains. These affections of the alimentary canal are often at- 
tended with all the symptoms of hypochondriasis ; as de- 
jection of mind, a constant and anxious attention to the 
slightest feelings, an imaginary aggravation of these, and 
an apprehension of danger from them. 

In the same atonic gout, the viscera of the thorax also 
are sometimes affected, and palpitations, faintings, and 
asthma, occur. 

In the head also occur, headachs, giddiness, apoplectic 
and paralytic affections. 

520.] When the several symptoms now mentioned occur 
in habits having the marks of a gouty disposition, this may 
be suspected to have laid the foundation of them, and espe- 
cially .wben either, in such habits, a manifest tendency to 
the inflammatory affection has formerly appeared ; or when 
the symptoms mentioned arc intermixed with, and are re- 
lieved by, some degree of the inflammatory gout. In such 



176 PRACTICE OF PHYSIC. 

cases there can be no doubt of considering the whole as a 
state of the gout. 

521.] Another state of the disease I name the retrocedent 

fout. This occurs when an inflammatory state of the joints 
as, in the usual manner, come on, but which, without 
arising to the ordinary degree of pain and inflammation, 
or, at least, without these continuing for the usual time, 
and receding gradually in the usual manner, they suddenly 
and entirely cease, while some internal part becomes affect- 
ed. The internal part most commonly affected is the sto- 
mach, which is then affected with anxiety, sickness, vo- 
miting, or violent pain ; but sometimes the internal part is 
the heart, which gives occasion to a syncope ; sometimes 
it is the lungs which are affected with asthma ; and some- 
times it is the head, giving occasion to apoplexy or palsy. 
In all these cases, there can be no doubt of the symptoms 
being all a part of the same disease, however different the 
affection may seem to be in the parts which it attacks. 

522.] The third state of irregular gout, which we name 
the misplaced, is when the gouty diathesis, instead of pro- 
ducing the inflammatory affection of the joints, produces 
an inflammatory affection of some internal part, and which 
appears from the same symptoms that attend the inflamma- 
tion of those parts arising from other causes. 

Whether the gouty diathesis does ever produce such in- 
flammation of the internal parts without having first produc- 
ed it in the joints, or if the inflammation of the internal 
part be always a translation from the joints previously 
affected, I dare not determine; but, even supposing the 
latter to be always the case, I think the difference of the 
affection of the internal part must still distinguish the/mis- 
placed from what I have named the retrocedent gout. 

523.] What internal parts may be affected by the mis.- 
placed gout I cannot precisely say, because I hare never 
met with any cases of the misplaced gout in my practice; 
and I find no cases of it distinctly marked by practical wri- 
ters, except that of a pneumonic inflammation. 

524.] There are two cases of a translated gout ; the one 
of which is an affection of the neck of the bladder, pro- 
ducing pain, strangury, and a catarrhus vesicae: The other 
is an affection of the rectum, sometimes by pain alone in 
that part, and sometimes by hemorrhoidal swelling there. 
In goutv persons, I have known such affections alternate 
with inflammatory affection of the joints : But whether to 



PRACTICE OF PHYSIC. m 

refer those affections to the retrocedent, or to the misplac- 
ed "-out, I will not presume to determine. 

525.] From the history which I have now delivered of 
the gout, I think it may be discerned under all its various 
appearances. It is, however, commonly supposed, that 
there are cases in which it may be difficult to distinguish 
gout from rheumatism, and it is possible there may be such 
cases : but, for the most part, the two diseases may be dis- 
tinguished with great certainty by observing the predispo- 
sition, the antecedents, the parts affected, the recurrences 
of the disease, and its connection with the other parts of 
the system ; which circumstances, for the most part, ap- 
pear very differently in the two diseases. 

526.] With respect to the gout, our next business is to 
investigate its proximate cause ; which must be a difficult 
task, and 1 attempt it with some diffidence. 

527.J Upon this subject, the opinion which has general- 
ly prevailed is, that the gout depends upon a certain mor- 
bific matter, always present in the body ; and that this mat- 
ter, by certain causes, thrown upon the joints or other parts, 
produces the several phenomena of the disease. 

528.] This doctrine, however ancient and general, ap- 
pears to me very doubtful ; for, 

First, There is no direct evidence of any morbific matter 
being present in persons disposed to the gout. There are 
no experiments or observations which shew that the blood, 
or other humors of gouty persons, are in any respect differ- 
ent from those of other persons. Previous to attacks of the 
gout, there appear no marks of any morbid state of the 
fluids ; for the disease generally attacks those persons who 
have enjoyed the most perfect health, and appear to be in 
that state when the disease conies on. At a certain period of 
the disease, a peculiar matter indeed appearsin gouty per- 
sons; (5 15.) but this, which does not appear in every instance, 
and which appears only after the disease has subsisted for 
a long time, seems manifestly to be the effect, not the cause, 
of the disease. Further, though there be certain acrids 
which, taken into the body, seem to excite the gout, (503.) 
it is probable that these acrids operate otherwise in exciting 
the disease, than by affording the material cause of it. In 
general, therefore, there is no proof of any morbific mat- 
ter being the cause of the gout. 

Secondly, The suppositions concerning the particular 
nature of the matter producing the gout, have been so va- 



178 PRACTICE OF PHYSIC. 

rious and so contradictor}' to each other, as to allow us to 
conclude, that there is truly no proof or* the existence of 
any of them. With respect to many of these suppositions, 
they are so inconsistent with chemical philosophy, and 
with the laws of the animal economy, that they must be 
entirely rejected. 

Thirdly, The supposition of a morbific matter being 
the cause of the gout, is not consistent with the pheno- 
mena of the disease, particularly with its frequent and 
sudden translations from one part to another. 

Fourthly, The supposition is further rendered improba- 
ble by this, that, if a morbific matter did exist, its ope- 
ration should be similar in the several parts which it at- 
tacks ; whereas it seems to be very different, being sti- 
mulant, and exciting inflammation in the joints, but se- 
dative and destroying the tone in the stomach : Which, 
upon the supposition of particular matter acting in both 
cases, is not to be explained by any difference in the part 
affected. 

Fifthly, Some facts, alledged in proof of a morbific 
matter, are not sufficiently confirmed, such as those 
which would prove the disease to be contagious. There 
is, however, no proper evidence of this, the facts given 
being not only few, but exceptionable ; and the negative 
observations are innumerable. 

Sixthly, Some arguments brought in favor of a mor- 
bific matter, are founded upon a mistaken explanation. 
The disease has been supposed to depend upon a morbific 
matter because it is hereditary : But the inference is not 
just ; for most hereditary diseases do not depend upon any 
morbific matter, but upon a particular conformation of 
the structure of the body, transmitted from the parent to 
the offspring ; and this last appears to be particularly the 
case in the gout. It may be also observed, that heredi- 
tary diseases, depending upon a morbific matter, always 
appear much more early in life than the gout commonly 
does. 

Seventhly, The supposition of a morbific matter being 
the cause of the gout, has been hitherto useless, as it has 
not suggested any successful method of cure. Particular 
suppositions have often corrupted the practice and have 
frequently led from those views which might be useful, 
and from that practice which experience had approved. 
Further, though the supposition of a morbific matter has 



PRACTICE OF PHYSIC. 179 

been generally received, it has been as generally neglected 
in practice. When the gout has affected the stomach, no- 
body thinks of correcting the matter supposed to be pre- 
sent there, but merely of restoring the tone of the moving 
fibres. 

Eighthly, The supposition of a morbific matter is quite 
superfluous; for it explains nothing, without supposing 
that matter to produce a change in the state of the moving 
powers ; and a change in the state of the moving powers, 
produced by other causes, explains every circumstance, 
without the supposition of a morbific matter; and, to this 
purpose, it may be observed, that many of the causes 
(503.) exciting the gout, do not operate upon the state of 
the fluids, but directly and solely upon that of the mov- 
ing powers. 

Lastly, The supposition of a morbific matter is also su- 
perfluous; because, without any such supposition, I think 
the disease can be explained in a manner more consistent 
with its phenomena, with the laws of the animal economy, 
and with the method of cure which experience has ap- 
proved. 

I now proceed to give this explanation ; but, before en- 
tering upon it, 1 must premise some general observations. 

529.] The first observation is, that the gout is a disease 
of the whole system, or depends upon a certain general 
conformation and state of the body, which manifestly ap- 
pears from the facts mentioned from (493. to 496.) But 
the general state of the system depends chiefly upon the 
state of its primary moving powers ; and therefore the 
gout may be supposed to be chiefly an affection of these. 

530.] My second observation is, that the gout is mani- 
festly an affection of the nervous system ;* in which the 
primary moving powers of the whole system are lodged. 
The occasional or exciting causes (503.) are almost all 
such as act directly upon the nerves and nervous system ; 
and the greater part of the symptoms of the atonic or re- 
trocedent gout arc manifestly affections of the same system 
519. and 521.) This leads us to seek for an explanation of 
the whole of the disease in the laws of the nervous system, 
and particularly the changes which may happen in the ba- 
lance of its several parts. 

* Boerhaave after describing the disease, says, Aphorism, 12G2. " From all which it ap- 
pears, that the proximate cause of the gout is a vitiated state of the most inir.ulc, and conse- 
quently nervous vessels of the body ; and also of that fluid which flows through the net vet" 



ISO PRACTICE OF PHYSIC. 

531.] My third observation is, that the stomach, which 
has so universal a consent with the rest of the system, is the 
internal part that is the most frequently, and often very 
considerably affected by the gout. The paroxysms of the 
disease are commonly preceded by an affection of the stom- 
ach ; (506.) many of the exciting causes (503.) act first up- 
on the stomach ; and the symptoms of the atonic and retro- 
cede.it gout (519. 521.) are most commonly and chiefly 
affections of the same organ. This observation leads us to 
remark, that there is a balance subsisting between the state 
of the internal and that of the external parts ; and, in par- 
ticular, that the state of the stomach is connected with that 
of the external parts ; (44.) so that the state of tone in the 
one may be communicated to the other. 

532.] These observations being premised, I shall now 
offer the following pathology of the gout. 

In some persons there is a certain vigorous and pletho- 
ric state of the system (495.) which, at a certain period of 
life, is liable to a loss of tone in the extremities. (498. 
505.) This is in some measure communicated to the whole 
system, but appears more especially in the functions of the 
stomach (506.) When this loss of tone occurs while the 
energy of the brain still retains its vigor, the vis medicatrix 
naturae is excited to restore the tone of the parts ; and ac- 
complishes it by exciting an inflammatory affection in some 
part of the extremities. When this has subsisted for some 
days, the tone of the extremities, and of the whole system, 
are restored, and the patient returns to his ordinary state of 
health. (510.) 

£33.] This is the course of things, in the ordinary form 
of the disease, which we name the regular gout ; but there 
are circumstances of the body, in which this course is in- 
terrupted or varied. Thus when the atony (505. 506.) 
has taken place, if the reaction (508.) do not succeed, the 
atony continues in the stomach, or perhaps in other inter- 
nal parts, and produces that state which we have, for rea- 
sons now obvious, named the atonic gout. 

534.] A second case of variation in the course of the 
gout is, when, to the atony, the reaction and inflammation 
have to a certain degree succeeded ; but, from causes either 
internal or external, the tone of the extremities, and per- 
haps of the whole system, is weakened ; so that the inflam- 
matory state, before it had either proceeded to the degree, 
or continued for the time, requisite for restoring the tone 



PRACTICE OF PHYSIC. 181 

of the system, suddenly and entirely ceases. Hence the 
stomach, and other internal parts, relapse into the state of 
atony ; and perhaps have this increased by the atony com- 
municated from the extremities : All which appears in 
what we have termed the retrocedent gout. 

535.] A third case of variation from the ordinary course 
of the gout, is, when, to the atony usually preceding, an 
inflammatory reaction fully succeeds ; but has its usual de- 
termination to the joints by some circumstances prevented ; 
and is therefore directed to an internal part, where it pro- 
duces an inflammatory affection, and that state of things 
which we have named the misplaced gout. 

536.] We have thus offered an explanation of the circum- 
stances of the system in the several states of the gout ; and 
this explanation we suppose to be consistent with the phe- 
nomena of the disease, and with the laws of the animal eco- 
nomy. There are indeed, with respect to the theory of the 
disease, several questions which might be put, to which 
we have not given any answer. But, though perhaps we 
could give an answer to many of these questions, it does 
not here appear necessary ; as at present we intend only to 
establish such general facts with regard to this disease, as 
may lay a foundation for the cure of it, so far as experience 
has enabled us to prosecute it. Proceeding, therefore, up- 
on the several parts of the pathology given, as so many 
matters of fact, I shall now consider what may be attempt- 
ed towards the cure of the disease. 

537.] In entering upon this, I must observe, in the first 
place, that a cure has been commonly thought impossible ; 
and we acknowledge it to be very probable, that the gout, 
as a disease of the whole habit, and very often depending 
upon original conformation, cannQt be cured by medicines, 
the effects of which arc always very transitory, and seldom 
extend to the producing any considerable change of the 
whole habit. 

538.] It would perhaps have been happy for gouty per- 
sons, if this opinion had been implicitly received by them ; 
as it would have prevented their having been so often the 
dupes of self-interested pretenders, who have either amus- 
ed them with inert medicines, or have rashly employed those 
of the most pernicious tendency. lam much disposed to 
believe the impossibility of a cure of the gout by medicines ; 
and more certainly still incline to think, that whatever may 
be the possible power of medicines, yet no medicine for cur- 

3 A 



182 PRACTICE OF PHYSIC. 

ing the gout has hitherto been found. Although almost 
every age has presented a new remedy, yet all hitherto of- 
fered have very soon been either neglected as useless, or 
condemned as pernicious. 

539.] Though unwilling to admit the power of medi- 
cines, yet I contend that a great deal can be done towards 
the cure of the gout by a regimen : And from what has 
been observed (497.) I am firmly persuaded, that any man 
who, early in life, will enter upon the constant practice of 
bodily labor, aud of abstinence from animal food, will be 
preserved entirely from the disease. 

Whether there be any other means of radically curing 
the gout I am not ready to determine. There are histories 
of cases of the gout, in which it is said, that by great emo- 
tions of mind, by wounds, and by other accidents, the 
symptoms have been suddenly relieved, and never again 
returned ; but how far these accidental cures might be 
imitated by ait, or would succeed in other cases, is at least 
extremely uncertain. 

540.] The practices proper and necessary in the treat- 
ment of the gout, are to be considered under two heads ; 
first, As they are to be employed in the intervals of parox- 
ysms ; or, secondly, As during the time of these. 

541.] In the intervals of paroxysms, the indications are, 
to prevent the return of paroxysms, or at least to render 
them less frequent, and more moderate. During the time 
of paroxysms, the indications are, to moderate the vio- 
lence, and shorten the duration of them as much as can be 
done with safety. 

542.] It has been already observed, that the gout may 
be entirely prevented by constant bodily exercise, and by 
a low diet ; and I am of opinion, that this prevention may 
take place even in persons who have a hereditary disposi- 
tion to the disease. I must add here, that, even when the 
disposition has discovered itself by several paroxysms of in- 
flammatory gout, I am persuaded that labor and abstinence 
wil. absolutely prevent any returns of it for the rest of life.* 
These, therefore, are the means of answering the first in- 
dication to be pursued in the intervals of paroxysms ; and 

* Several cases are to he met with In practical authors, which confirm this observation. Van 
SwieteB relaies the case of a priest, who enjoyed a rich living, and had lon» been an old con- 
«iant iuffererin the gout ; but happening ai last to be taken by the pirates of Barbary, was de- 
taint d tl ere in a slate of slavery lor the apace of two years, and kept constantly at work in the 
galleys, with only a very spare diet. The regimen he there underwent had this good effect,., 
ti.at after he was ransomed (torn his captivity, having lost his troublesome and monstrous fatness- 
he never once had a fit of Uiegout, though he. lived several years after the event ha ppenetf. 



PRACTICE OF PHYSIC. 183 

I must here offer some remarks upon the proper use of these 
remedies. 

543. J Exercise, in persons disposed to the gout, is di- 
rected to two purposes : One of these is the strengthening 
of the tone of the extreme vessels ; and the other, the 
guarding against a plethoric state. For the former, if ex- 
ercise be employed early in life, and before intemperance 
has weakened the body, a very moderate degree of it will 
answer the purpose ; and for the latter, if abstinence be at 
the same time observed, little exercise will be necessary. 

544.] With respect to exercise, this in general is to be 
observed, that it should never be violent ; for if violent, it 
cannot be long continued, and must always endanger the 
bringing on an atony in proportion to the violence of the 
preceding exercise. 

545.] It is also to be observed, that the exercise of gesta- 
tion though considerable and constant, if it be entirely with- 
out bodily exercise, will not answer the purpose in prevent- 
ing the gout. For this end, therefore, the exercise must 
be in some measure, that of the body, and must be mode- 
rate, but at the same time constant and continued through 
life. 

546.] In every case and circumstance of the gout in 
which the patient retains the use of his limbs, bodily exer- 
cise, in the intervals of paroxysms, will always be useful ; 
and, in the beginning of the disease, when the disposition 
to it is not yet strong, exercise may prevent a paroxysm 
which otherwise might have come on. In more advanced 
states of the disease, however, when there is some disposi- 
tion to a paroxysm, much walking will bring it on ; either 
as it weakens the tone of the lower extremities, or as it ex- 
cites an inflammatory disposition in them ; and it is proba- 
ble, that in the same manner strains or contusions often 
bring on a paroxysm of the gout. 

547.] Abstinence, the other part of our regimen (539.) 
for preventing the gout, is of more difficult application. 
If an abstinence from animal food be entered upon early in 
life, while the vigor of the system is yet entire, we have no 
<loubt of its being both safe and effectual ; but if the motive 
for this diet shall not have occurred till the constitution 
shall have been broken by intemperance, or by the decline 
of life, a low diet may then endanger the bringing on an 
atonic state, 

£48.] Further, if a low diet be entered upon only in the 



184 PRACTICE OF PHYSIC. 

decline of life, and be at the same time a very great change 
in the former manner of living, the withdrawing of an ac- 
customed stimulus of the system may readily throw this into 
an atonic state.* 

549.] The safety of an abstemious course may be great- 
er or less according to the management of it. It is ani- 
mal food which especially disposes to the plethoric and in- 
flammatory state, and that food is to be therefore especially 
avoided ; but, on the other hand, it is vegetable aliment of 
the lowest quality that is in danger of weakening the system 
too much, by not affording sufficient nourishment ; and 
more particularly of weakening the tone of the stomach by 
its acescency. It is therefore a diet of a middle nature that 
is to be chosen ; and milk is precisely of this kind, as con- 
taining both animal and vegetable matter. 

As approaching to the.nature of milk, and as being a ve- 
getable matter containing the greatest portion of nourish- 
ment, the farinaceous seeds are next to be chosen, and are 
the food most proper to be joined with milk. 

550.] With respect to drink, fermented liquors are use- 
ful only when they are joined with animal food, and that 
by their acescency ; and their stimulus is only necessary 
from custom. When, therefore, animal food is to be avoid- 
ed, fermented liquors are unnecessary ; and, by increasing 
the acescency of vegetables, these liquors may be hurtful. 
The stimulus of fermented or spirituous liquors, is not ne- 
cessary to the young and vigorous; and, when much em- 
ployed, impairs the tone of the system. These liquors, 
therefore, are to be avoided, except so far as custom and 
the declining state of the system may have rendered them 
necessary. For preventing or moderating the regular gout, 
water is the only proper drink. 

551.] With respect to an abstemious course, it has been 
supposed that an abstinence from animal food and ferment- 
ed liquors, or the living upon milk and farinacea alone for 
the space of one year might be sufficient for a radical cure 
of the gout ; and it is possible that, at a certain period of 
life, in certain, circumstances of the constitution, such a 
measure might answer the purpose. But this is very doubt- 
ful ; and it is more probable that the abstinence must, in a 
great measure, be continued, and the milk diet be persisted 
in, for the rest of life. It is well known, that several per- 

* A sudden change from a full to a spare diet was justly enumerated among the occasional 
eauics of the tout in article 503. 



PRACTICE OF PHYSIC. iss 

sons who had entered on an abstemious course, and had 
been thereby delivered from the gout, have, however, upon 
returning to their former manner of full living, had the 
disease return upon them with as much violence as before, 
or in a more irregular and more dangerous form. 

552.] It has been alledged, that, for preventing the re- 
turn of the gout, blood-letting, or scarifications of the 
feet, frequently repeated, and at stated times, may be 
practised with advantage ; but of this I have had no expe- 
rience. 

553.] Exercise and abstinence are the means of avoid- 
ing the plethoric state which gives the disposition to the 
gout ; and are therefore the means proposed for prevent- 
ing paroxysms, or at least for rendering them less frequent, 
and more moderate. But many circumstances prevent the 
steadiness necessary in pursuing these measures; and there-* 
fore, in such cases, unless great care be taken to avoid the 
exciting causes, the disease may frequently return ; and in 
many cases, the preventing of paroxysms is chiefly to be 
obtained by avoiding those exciting causes enumerated in 
(503.) The conduct necessary for avoiding them, will be 
sufficiently obvious to persons acquainted with the doc- 
trines of the Hygieine, which I suppose to have been de- 
livered in another place. 

554.] A due attention in avoiding those several causes 
(502. 503.) will certainly prevent fits of the gout; and th« 
taking care that the exciting causes be never applied in a 
great degree, will certainly render fits more moderate 
when they do come on. But, upon the whole, it will ap- 
pear, that a strict attention to the whole conduct of life, 
is in this matter necessary;* and therefore, when the pre- 
disposition has taken place, it will be extremely difficult 
to avoid the disease. 

555.] I am indeed firmly persuaded, that, by obviating 
the predisposition, and by avoiding the exciting causes, 
the gout may be entirely prevented : But as the measures 
necessary for this purpose, will in most cases, be pursued 

• The physician has more difficulty in persuading his patients to a proper regimen in the gout 

than in any oilier disease ; and it he would gain reputation, he ought to pay peculiar attention 

to this pari of practice, and use his utmost art in convincing Ins patient of the necessity of an ab- 

lliet, and a regular conduct. 

Gouty p in-ra ly the genuine offspring of jolly Bacchus, and prefer the transient 

indulgence of tbeir jovial inclinations to the ransom of whole vears of torment at the easv price 

i sobriety and temperance, mm the invincible (Aueen of tortures, as Lucian calls her, 

ivinevs them of their errors They are then anxious for medical advice, and alter con- 

sulting the physician, they arc willing implicitly to obey his strictest injunctions, They seldom, 

Jiowevcr, then find much relief; and remain living proofs of the truth of the adage; 

sero meuicina paratur, 

Cum mala per longus invalucre moras. 



136 PRACTICE OF PHYSIC. 

with difficulty, and even with reluctance, men have beea 
very desirous to find a medicine which might answer the 
purpose without any restraint on their manner of living. 
To gratify this desire, physicians have proposed, and, to 
take advantage of it, empirics have feigned, many reme- 
dies, as we have already observed. Or what nature seve- 
ral of these remedies have been, I cannot certainly say ; 
but, of those which are unknown, we conclude, from 
their having been only of temporary fame, and from their 
having soon fallen into neglect, that they have been either 
inert or pernicious, and therefore 1 make no inquiry after 
them ; and shall now remark only upon one or two known 
remedies for the gout, which have been lately in vogue. 

556.] One of these is what has been named in England 
the Portland Powder.* This is not a new medicine, but 
is mentioned by Galen, and, with some little variation in. 
its composition, has been mentioned by the writers of al- 
most every age since that time. It appears to have been 
at times in fashion, and to have again fallen into neglect ; 
and I think that this last has been owing to its having been 
found to be, in many instances, pernicious. In every in- 
stance which I have known of its exhibition for the length 
of time prescribed, the persons who had taken it were in- 

* This medicine was so called from one of the Dukes of Portland being cured by it of as 
hereditary and inveterate gout. It consists of equal parts of the following bitter aromatics:-. 
viz. Rad. anstolochiae rotunda?, Rad.gentiana?, Summitat. chamedryos, Summitat. chamjepityos, 
Summitat. centaur, min. A drachm of this powder is ordered to be taken, in any convenient 
vehicle, as a little wine, broth, tea, &c. in a morning, fasting, the patient tasting nothing for an 
hour and an half after it; k must be used in this do-.: for three months without the least interrup- 
tion: Forty-five grains are to be taken daily in the same manner, for the succeeding three 
months: half a drachm every day, for the next six months; and half a drachm every other day, 
during the second year. It is sometimes two years complete before any change be produced, 
but the patient must not therefore abandon the medicine, but continue its use. 

These aromatic bitters have been long in use as remedies for the gout. We find Galen pre- 
scribing in this disease, the seeds and tops of wild rue, birth-wort, lesser centaury, gentian, ftc. 
either singly, or mixed in certain proportions. Trallian describes similar antidotes, which he 
tays, must be continued for a great length of time, viz. six or seven months, or even for a year 
and upwards. The tetra-pharmacon of Aetius, composed of gentian, birth-wort, bay-berries, 
and myrrh, is a similar remedy, and is also directed to be used for a great length of time. Ca- 
llus Aurclianus likewise mentions the bitters to be long used in the gout, and he gives them the 
apposite epithet of annalia. The Diatesseron, which has not been long thrown out of our shops, 
and is still retained in some of the foreign pharmacopoeias, is of the same kind. 

The use of these medicines has doubtless in many cases completely cured the gout; but in 
many cases, even in those that have been cured, fatal diseases liave supervened. The ancients 
were well aware of the danger of an indiscriminate use of these medicines: "Many," says 
Calen, " of a moderate and slender habit of body, have lost their life by the use of drinks com- 
posed of thdse kinds of remedies, their blood being dried up. The numerous arthritic cases 
cured by these medicines, encouraged gouty people to have recourse to them indiscriminately, 
and without reflecting that those, who had been cured by them, were of a humid and phleg- 
matic habit, to whom medicines of this sort might be administered with safety." .^gineta has 
a similar passage. " Those," says he, " who endeavor to remove the disease enlirelv by medi- 
cines, to be used through the whole year, will doubtless do service to such patients' as are in- 
fested, with pituitous and excrenven'itious humors in their joints, but they will hasten an un- 
timely' death in persons of a dry and hot habit of body, by forcibly driving the morbific matter 
on the intestines, kidneys, lungs, or some other of the principal bowels." 

The ancients, then, were aware of the danger attending the promiscuous use of these reme- 
dies; and the moderns are still more convinced of that danger : hence these aromatic bittei 
are entirely laid aside, and in their place the Peruvian bark is the duly ionic now a>ed in thei? 
cases. 



PRACTICE OF PHYSIC. j 8 7 

deed afterwards free from any inflammatory affection of the 
joints ; but they were affected with many symptoms of 
the atonic gout ; and all, soon after finishing their course 
of the medicine, have been attacked with apoplexy, asth- 
ma, or dropsy, which proved fatal. 

557.] Another remedy which has had the appearance of 
preventing the gout, is an alkali in various forms, such as 
the fixed alkali both mild and caustic, lime water, soap, 
and absorbent earths. Since it became common to exhi- 
bit these medicines in nephritic and calculous cases, it has 
often happened that they were given to those who were at 
the same time subject to the gout; and it has been observ- 
ed, that under the use of these medicines, gouty persons 
have been longer free from the fits of their disease.* That, 
however the use of these medicines has entirely prevented 
the returns of gout, I do not know; because I never push- 
ed the use of those medicines for a long time, being ap- 
prehensive that the long continued use of them might pro- 
duce a hurtful change in the state of the fluids. 

558.] With respect to preventing the gout, I have only 
one other remark to offer. As the preventing the gout de- 
pends very much on supporting the tone of the stomach, 
and avoiding indigestion ; so costiveness, by occasioning 
this is very hurtful to gouty persons. It is therefore neces- 
sary for such persons to prevent or remove costiveness, 
and by a laxative medicine, when needful; but it is at the 

* Some remarkable cases have lately occurred in this city of the efficacy of aerated alkaline 
water, in preventing the returns of the paroxysms of the gout. It requires to be taken for a 
great length of time, to insure success ; out the patient is encouraged to persevere in its use, 
in consequence of a speedy removal of some of the most troublesome symptoms. 

The method of making it is described by several authors ; but, for the sake of those readers 
who are unacquainted with the process, 1 shall give an abstract of it. 

Dissolve three ounces, Troy weight, of good salt of Tartar in a gallon and a half of rain wa- 
ter, or good soft spring water ; nitre the selution, and put as much of it into the middie glass 
ol Parker's machine as will completely fill the vessel, reserving the remainder for a subsequent 
making. The effervescing materials must then be put into the Tower vessel, and a gentle stream 
nf fixed air must be mule to pass through the liquor, till it tastes evidently acidulous, which 
will probably require forty-eight or sixty hours, or in summer more. 

The melhod of managing the effervescence is of considerable consequence ; for, if it is to» 
violent at first, much air escapes through the vessels without effect. Ascertain, by previous 
experiment, how much of the vitriolic acid, which you have procured, for it is of very differ- 
ent strengths in the shops, will saturate a drachm of the chalk. Put four ounces of dry powdered) 
chalk into the lower vessel, and shake it to one side : under that side put a wedge, so as to raise 
it auout an inch and an half from the table. With a long funnel, which reaches to the bottom of 
the vessel, pour in the quantity ot vitriolic acid necessary for the saturation, which will run 
down to the other side ot the vessel, and not come into contact with the chalk : through the 
same funnel, pour very slowly as much water as will be sufficient to cover about a fourth part of 
the chalk as it then lies. The vessel being gently skaken occasionally, the effervescence will go 
on very slowly, and the alkaline liquor will be sooner and more effectually saturated, than if 
the effervescence had been too violent. If the materials are not sufficient for giving an acidu- 
lous taste to the liquor, the lower vessel must be washed, and fresh chalk and acid again put 
mi. lit. 

The dose of this water is half a pint about noon, and another in the evening. In urgent cases 
half a pint has been given morning, noon, ami night, lor a considerable time together, without 
disagreeing with the stomach, or injuring the appetite or general health of the patient. If it 
iitulent, a tea-spoon ful or two, uut not more, of "spirituous cinnamon water may be 
taken in aachdoM). It it inflames, or too violently irritates the urinary passages, five or ten, 
•jj in urgent case-,, twenty drops of laudanum, may betaken with each dose ol lha water. 



183 PRACTICE OF PHYSIC. 

same time proper, that the medicine employed should be 
such as may keep the belly regular, without much purg- 
ing. Aloetics, rhubarb, magnesia alba, or flowers or sul- 
phur, may be employed, as the one or the other may hap- 
pen to be best suited to particular persons.* 

559.]. These are the several measures (from 541. to 558.) 
to be pursued in the intervals of the paroxysms; and wc 
arc next to mention the measures proper during the time 
of them. 

560.] As during the times of paroxysms the body is in 
a feverish state, no irritation should then be added to it ; 
and every part, therefore, of the antiphlogistic regimen, 
(130. to i 33.) except the application of cold, ought to be 
strictly observed. 

Another exception to the general rule may occur when 
the tone of the stomach is weak, and when the patient has 
been before much accustomed to the use of strong drink ; 
for it then mav be allowable, and even necessary, to give 
some animal food, and a little wine.f 

* The following formula may be used in particular cases: 

R. Aloes Socotorin. 5». 

Gum. Guaiac. 3iii« 

Tinct. Sacra, q. s. 

M. f. massa, in pilulas equales xv. dividenda ; quarum 
sumat iii. vel. iv. pro re nata. 
R. Pulv. Rad. Rhei, 5iii. 

Magnes. alb. §{£>. 

Gum. Guaiac. 5"* 

Confect. Aromat. 3ii. 

Syrup, comm. q. s. 

M. f. Elect, cujus sumat magnitudinem juglandis ma- 
ne et vespere, vel pro re nata. 

This last medicine has been extremely beneficial in removing costiveness. and in giving a 
lone to the stomach. 

An ounce, or an ounce and a half, or two ounces of the tinctura sacra, is also a good purge 
for gouty persons. 

The Elixir Senna; is likewise a good medicine where we cannot use aloetic purges, as in cases 
of piles: in these cases also we may use sulphur; of which the following form is very convenieDt. 

R. Flor. Sulphuris, 5ii. 
Elect. Lenitivi, §ii. 
Pulv. Rad. Jalap. 3"- 

Zinzib. 3ii, 
Syr. Simpl. q. s. 

M. f. Elect, cujus sumat quantitatem juglandis pro re- 
nata. 

+ The wine in these cases should be of the best kind, and such as are not apt to turn sour on the 
stomach. The dry wines, as Sherry and Madeira are most proper, while both the rich sweet 
wines and the austere thin acid win«s are equally improper. 



PRACTICE OF PHYSIC. 189 

561 .] That no irritation is to be added to the system dur- 
ing the paroxysms of gout, except in the cases mentioned, 
is entirely agreed upon among physicians : But it is a more 
difficult matter to determine whether, during the time of 
paroxysms, any measure may be pursued to moderate the 
violence of reaction and of inflammation. Dr. Sydenham 
has given it as his opinion, that the more violent the inflam- 
mation and pain, the paroxysms will be the shorter, as well 
as the interval between the present and next paroxysm long- 
er ; and, if this opinion be admitted as just, it will forbid 
the use of any remedies which might moderate the inflam- 
mation ; which is, to a certain degree, undoubtedly neces- 
ary for the health of the body. On the other hand, acute 
pain presses for relief ; and, although a certain degree of 
inflammation may seem absolutely necessary, it is not cer- 
tain but that a moderate degree of it may answer the pur- 
pose: And it is even probable, that, in many cases, the vio- 
lence of inflammation may weaken the tone of the parts, 
and thereby invite a return of paroxysms. It seems to me 
to be in this way, that, as the disease advances, the parox- 
ysms become more frequent. 

562. From these last considerations, it seems probable, 
that, during the time of paroxysms, some measures may be 
taken to moderate the violence of the inflammation and 
pain ; and particularly, that in first paroxysms, and in the 
young and vigorous, blood-letting at the arm may be prac- 
tised with advantage. But I am persuaded, that this prac- 
tice cannot be repeated often with safety ; because blood- 
letting not only weakens the tone of the system, but may 
also contribute to produce plethora. I believe, however, 
that bleeding by leeches on the foot, and upon the inflamed 
part, may be practised, and repeated with greater safety; 
and I have known instances of its having been practised 
with safety, to moderate and shorten paroxysms ; but how 
far it may be carried, we have not had experience enough 
to determine. 

563.] Besides blood-letting, and the antiphlogistic re« 
gimeu, it has been proposed to employ remedies for mo- 
derating the inflammatory spasm of the part affected, 
such as warm bathing and emollient poultices. These 
have sometimes been employed with advantage and safety ; 
but at other times, have been found to give occasion to a 
retrocession of the gout.* 

•On (his account these topical remedies ought to be used with peat caution : the temp*. 

2b 



i90 PRACTICE OF PHYSIC. 

564.] Blistering is a very effectual means of relieving 
and discussing a paroxysm of the gout ; but has also fre- 
quently had the effect of rendering it retrocedent. f 

565.] The stinging with nettles I consider as analogous 
to blistering ; and I think it probable that it would be at- 
tended with the same danger. 

566.] The burning with moxa,t or other substances, I 
consider as a remedy of the same kind. I have had indeed 
no evidence of this proving hurtful ; but neither have I 
had any proper evidence of its having proved a radical 
cure. 

567.] Camphire, and some aromatic oils, have the 
power of allaying the pain, and of removing the inflam- 
mation from the part affected ; but these remedies com- 
monly make the inflammation only shift from one part to 
another, and therefore with the hazard of its falling upon 
a part where it may be more dangerous : and they have 
sometimes rendered the gout retrocedent. 

568.] From these reflections (563. et seq.) it will ap- 
pear, that some danger must attend every external appli- 
cation to the parts affected during a paroxysm ; and that 
therefore the common practice of committing the person 
to patience and flannel alone, is established upon the best 
faun elation. 

569.] Opiates give the most certain relief from pain ; 
but, when given in the beginning of gouty paroxysms, 
occasion these to return with greater violence. When, 
however, the paroxysms shall have abated in their vio- 
lence, but still continue to return, so as to occasion pain- 
ful and restless nights, opiates may be then given with 
safety and advantage, especially in the case of persons 

lary relief which they afford, by procuring an intermission of the pain, is agreeable to the patient, 
but it is frequently the occasion of an exacerbation of all the symptoms. 

+ This is a very <L n;'erous practice. Blisters are however extremely useful, in bringing back 
the retrocedent gout to the part originally affected ; but, the violent degree of pain that ac- 
compav.ies the gout, when brought to a part already irritated by the blisters, frequently prevents 
a patient who has once suffered it, from allowing it a second time It is, however, so impor- 
tant and necessary a practice, that it ought not to he omitted. As soon as the gout has been 
brought hack to its original place, the blisters must be immediately removed, a piece of soft 
linen dipped in fresh oil, applied to the part, and the whole well wrapt up in soft flannel : a 
moderate degree of heat must be preserved in the flannel, and the patient must be encouraged 
to bear with patience the violent pain which he suffers. 
- t Moxa is a soft lanuginous substance prepared in Japan, from the young leaves of a species 
of Artemisia, by beating them when thoroughly dried, and rubbing them between the fingers 
till nothing but the finest fibres remain. 

A little cone of this cotiony >ubstancc is laid upon the skin, which is previously moistened to 
prevent the cone from sliding off : Fire is set to the apex of the cone, and it is suffered to burn 
till it extinguishes itself. A small eschar is produced and the ulcer either healed or kept open 
as occasion requires. 

Cotton impregnated with a small quantity of a solution of nitre, and afterwards dried, answers 
tk» end as etlectually as the Japonese inoxs*. 



PRACTICE OF PHYSIC. 1*91 

advanced in life, and who have been often affected with 
the disease.* 

510.] When, after paroxysms have ceased, some swel- 
ling and stiffness shall remain in the joints, these symp- 
toms are to be discussed by the diligent use of the flesh- 
brush. 

571.] Purging, immediately after a paroxysm, will be 
always employed with the hazard of bringing it on again. 

512.] I have now finished what has occurred to be said 
upon the means of preventing and curing the regular 
gout ; and shall now consider its management when it has 
become irregular ; of which, as I have observed above, 
there are three different cases. 

573.] In the first case, which I have named the Atonic 
Gout, the cure is to be accomplished by carefully avoid- 
ing all debilitating causes ; and by employing, at the same 
time, the means of strengthening the system in general, 
and the stomach in particular. 

574.] For the avoiding debilitating causes, I must re- 
fer to the doctrines of the Hygieine, as in 553. 

575.] For strengthening the system in general, I must 
recommend frequent exercise on horseback, and moderate 
walking. Cold bathing also may answer the purpose, 
and may be safely employed, if it appear to be powerful 
in stimulating the system, and be not applied when the 
extremities are threatened with any pain.f 

For supporting the tone of the system in general, when 
threatened with atonic gout, some animal foodj ought to 
be employed, and the more acescent vegetables ought to 
be avoided. In the same case, some wine§ also may be 
necessary ; but it should be in moderate quantity, and of 
the least acescenl kinds ; and, if every kind of wine shall 
be found to increase the acidity of the stomach, ardent 
spirits and water must be employed. || 

* The best form for exhibiting opium in these cases, is the Confectio Opiaia of the London 
Pharmacopeia, or the Electanum Thebaicum of the Edinburgh. The dose of the former is half 
a drachm, but of tlie latter a drachm and an half. 

As opiates ought never to be administered where the inflammation Is violent, but only in such 
cases as are attended with little or no inflammation, these warm opiates cannot be improper. If 
liowever the practitioner should think either of the above formulas too hot, he can have recourse 
to the Tinctura Thebaica. 

t Cojd bathing is a doubtful remedy, and ought to be used with caution. If it does not prove 
a tonic, it ought to be abandoned ; and we know by experience that it frequently debilitates. 

t The use of animal food is absolutely necessary, and such ought to be chosen as is most nu- 
tritive. Beef or mutton have been with propriety preferred to all other animal food, and some 
iMiincnt practitioners have recommended steaks to every other mode of dressing beef and mut- 
ton. Slews, hashes, pyes, and all high seasoned dishes, ought to be avoided. 

il he wine which a gouty person uses, ought to be generous and good, as Madeira, Sherry. 
Sec. the thin acescent wines, as hock, claret, tkc. always do mischief. 

II In order the more effectually toguard against acescencv, the spirits and water ought, if pos- 
iltlc, to betaken without su;jj, and wlj. No drink is'perhap.inoic prejudicial foi gwitj 



192 PRACTICE OF PHYSIC. 

576.] For strengthening the stomach, bitters and the 
Peruvian bark may be employed ; but care must be taken 
that they be not constantly employed for any great length 
of time. Compare 556. 

The most effectual medicine for strengthening the sto- 
mach is iron, which may be employed under various 
preparations ; but, to me, the best appears to be the rust 
in fine powder, which may be given in very large doses.* 

For supporting the tone of the stomach, aromatics may 
be employed ; but should be used with caution, as the fre- 
quent and large use of them may have an opposite effect; 
and they should therefore be given only in compliance 
with former habits, or for palliating present symptoms. 

When the stomach happens to be liable to indigestion, 
gentle vomits may be frequently given ; and proper laxa- 
tivesf should be always employed to obviate, or to re- 
move costiveness. 

577.] In the atonic gout, or in persons liable to it, to 
guard against cold is especially necessary ; and the most 
certain means of doing this is, by repairing to a warm cli- 
mate during the winter season. 

578.] In the more violent cases of the atonic gout, 
blistering the lower extremities may be useful ; but that 
remedy should be avoided when any pain threatens the 
extremities. In persons liable to the atonic gout, issues 
may be established in the extremities, as, in some measure, 
a supplement to the disease. 

579.] A second case of the irregular gout, is that which 
I have named the Retrocedent. When this affects the 
stomach and intestines, relief is to be instantly attempted 
by the free use of strong wines, joined with aromatics, and 
given warm ; or if these shall not prove powerful enough, 
ardent spirits must be employed, and are to be given in a 
large dose. In moderate attacks, ardent spirits impreg- 

patient?, than what is called rich punch, viz. with a large quantity of sugar and lemon, espe- 
cially when taken warm. 

* The dose must be very small at first, not exceeding four or live grains in the day ; the doses 
may be daily increased two grains, till we arrive at ten or twelve, and after two or three days, 
ten "rains mar be given twice a day. Aromatics always make it sit easier on the stomach thaa 
it would do if 'taken alone; the most convenient foim therefore is the following: 

R. Rubig. Martis, gr. 10. 
Confect. Card. 5 ft. 
Syr. Croci, q. s. 
M. f. bolus. 

After the patient has taken two of these boluses for three or four days, he may proceed ta 
take three of them ; and after a few more days, if the stomach is not disordered, each bolus 
may be dailv increased till we arrive at 24, or even 30 grains, thrice a day. 

+ The proper laxatives for gouty constitutions, are mentioned in a note on article 558. 



PRACTICE OF PHYSIC. 193 

«ated with garlic, or with asafcetida, may be employed ; 
or, even without the ardent spirits a solution of asafoetida 
with the volatile alkali may answer the purpose. Opiates 
are often an effectual remedy, and may be joined with 
aromatics, as in the Electuarium Thebaicum ;* or thev 
may be usefully joined wi^h volatile alkali and camphire.f 
Musk has likewise proved useful in this disease. 

When the affection of the stomach is accompanied with, 
vomiting, this may be encouraged, by taking draughts of 
warm wine, at first with water, and afterwards without it ; 
having at length recourse if necessary, to some of the re- 
medies above mentioned, and particularly the opiates. 

In like manner, if the intestines be affected with diai'- 
rhcea, this is to be at first encouraged, by taking plentiful- 
ly of weak broth ; and when this shall have been done suf- 
ficiently, the tumult is to be quieted by opiates. 

580.] When the retrocedent gout shall affect the lungs, 
and produce asthma, this is to be cured by opiates, by an- 
tispasmodics, % and, perhaps, by blistering on the breast 
or back. 

581.] When the gout, leaving the extremities, shall af- 
fect the head, and produce pain, vertigo, apoplexy, or 
palsy, our resources are very precarious. The most pro- 
bable means of relief is, blistering the head: and if the 
gout shall have receded entirely from the extremities, 
blisters may be applied to these also. Together with these 

•Tlie following form is extremely efficacious, and at the same time pleasant to the Uste; it 
may be repeated diree or tour times, if the first does not procure relief. 

R. Elect. Thebaic. 31. 

Aq. Cinnamom. spirituosas, Bi.f^.. 
Syr. Croci, 3"* 
M. f. haust. 

+ The best way of giving these medicines is in the following form: 

R. Opii purificati, gr. i. 
Camphor, gr. xii. 
Spt. Vini, q. s. 
Confect. Cardiac, ^,'u. 
M. f. bolus. 

Or the camphor may be made into a bolus with a drachm of the Elect. Thebaic, and forty 
drops of the bpirilus Aroraaticus, in a glass of strong wine, as Madeira or Sherry, may be drank 
Jiier it. 

t The Spiritus Ethereus Vitriolicus is a medicine used with much success in these cases. The 
h is from twenty to thirty drops in a glass of wine. The ethereal spirit is so very vola- 
tile, that it will wholly evaporate, if it be suffered to stand in the wine for a few minutes ; it must 
therefore be drank speedily : and the dose may be repeated every two hours, in cases of emer- 
gency. In most cases laudanum will answer everj -purpose. Ammoniacum has been much 
recommended, and its powers in cases of gouty asthma have freqnently been very conspicuous: 
Jt may be given independently of the opiates. Two drachms of it may be made into an emul- 
lion with six ounces of water : and a souple of uble->poonfulIs of this emulsion may be given 
every two or three hours. , 



!9* PRACTICE OF PHYSIC. 

blisterings, aromatics, and the volatile alkali, may be 
thrown into the stomach.* 

582.] The third case of the irregular gout is -what I have 
named the Misplaced ; that is, when the inflammatory af- 
fection of the gout, instead of falling upon the extremities 
falls upon some internal part. In this case, the disease is 
to be treated by blood-letting, and by such other remedies 
as would be proper in an idiopathic inflammation of the 
same parts. 

583.] Whether the translation so frequently made from 
the extremities to the kidneys, is to be considered as an 
instance of the misplaced gout, seems, as we have said 
before, uncertain ; but I am disposed to think it something 
cut; and therefore am of opinion, that, in the Ne- 
phralgia Calculosa produced upon this occasion, the reme- 
dies of inflammation are to be employed no farther than 
they may be otherwise sometimes necessary in that disease, 
arising from other causes than the gout. 

* LUUe relief lias ever been obtained in these cases from internal remedies. Large doses of 
the Spiritus Aromaticus have been thought serviceable, but the chief dependence is on the ef- 
fcci of blisters un the extremities, especially the feet, with warm fomentations to the legs, and 
rubbing the legs with a flesh brush, impregnated with plenty of dry flour of mustard. 



BOOK III. 

OF EXANTHEMATA, OR ERUPTIVE 
FEVERS. 



584.] r I A HE diseases comprehended under this title, 
JL which make the third Order of Pyrexiae in 
our Nosology, are in general such as do not arise but up- 
on occasion of a specific contagion applied, which first 
produces fever, and afterwards an eruption upon the sur- 
face of the body ; and which diseases, for the most part 
affect persons but once in the course of their lives. 

585.] Whether the character of the Order may be thus 
limited, or if the Order may be allowed to comprehend al- 
so the eruptive fevers produced by a matter generated in 
the body itself, and likewise those cases of eruption which 
do not depend upon contagion, or upon a matter generat- 



PRACTICE OF PHYSIC. 195 

ed before the fever, but upon a matter generated in the 
course of the fever, I am not ready to determine. Of 
the diseases enumerated by the Nosologists as Exanthema- 
ta, there are certainly three different kinds, which may be 
distinguished by the circumstances mentioned in this and 
the preceding paragraph. Of the first kind are the Small 
Pox, the Chicken Pox, the Measles, the Scarlet Fever, and 
the Plague. Of the second kind seems to be the Erysipe- 
las; and of the third kind I judge the Miliaria and Pete- 
chia to be. But as I am not sufficiently confident in the 
facts which should support these distinctions, or which 
would enable us to apply them in all cases; I go on in this 
book to treat of almost all the exanthemata enumerated 
by preceding Nosologists, with only some difference in the 
arrangement from what it was in my former editions. 



CHAPTER I. 

OF THE SMALL POX. 

586.] HHHE small pox is a disease arising from a con- 
X tagion of a specific nature, which first pro- 
duces a fever; and on the third or fourth day thereof, pro- 
duces an eruption of small red pimples. These are after- 
wards formed into pustules, containing a matter, which, in 
the course of eight days from the time of the eruption, is 
changed into pus. After this, the matter dries, and falls 
off in crusts. 

587.] This is a general idea of the disease ; but there 
are two particular forms or varieties of it, well known un- 
der the appellations of the Distinct and Confluent, which 
require to be specially described. 

588.] In the former, or the distinct small pox, the erup- 
tive fever is moderate, and appears to be evidently of the 
inflammatory kind, or what we name a Synocha. It gene- 
rally comes on about mid-day, with some symptoms of a 
cold stage, and commonly with a considerable langour 
and drowsiness. A hot stage is soon formed, and becomes 
more considerable on the second and third days. During 
this course, children are liable to frequent startings from 
their slumbers; and adults, if they are kept a-bed, are 
disposed to much sweating. On the third day* children 



196 PRACTICE OF PHYSIC. 

are sometimes affected with one or two epileptic fits. To- 
wards the end of the third day, the eruption commonlv 
appears, and gradually increases during the fourth ; ap- 
pearing first upon the face, and successively on the infe- 
rior parts, so as to be completed over the whole body on 
the fifth day. 

From the third day the fever abates ; and against the 
fifth it entirely ceases. The eruption appears first in small 
red spots, hardly eminent, but by degrees rising into pim- 
ples. These are generally upon the face in small number ; 
but even when more numerous, they are separate and dis- 
tinct from one another. On the fifth or sixth day, a small 
vesicle, containing an almost colorless or whey colored 
fluid, appears upon the top of each pimple. For two 
days, these vesicles increase in breadth only., and there is 
a small hollow pit in their middle ; so that it is only against 
the eighth day that they are raised into spheroidical pus- 
tules. 

These vesicles or pustules, from their first formation, 
continue to be surrounded with an exactly circular inflam- 
ed margin, which, when the pustules are numerous, diffu- 
ses some inflammation over the neighboring skin, so as 
to give somewhat of a damask rose-color to the spaces be- 
tween the pustules. As the pustules increase in size, if 
they be numerous on the face, against the eighth day the 
whole of the face becomes considerably swelled; and, in 
particular, the eye-lids are so much swelled as entirely to 
shut the eyes. 

As the disease thus proceeds, the matter in the pustules 
becomes by degrees more opaque and white, and at length 
of a yellowish color. On the eleventh day, the swelling 
of the face is abated, and the pustules seem quite full. 
On the top of each a darker spot appears ; and at this place 
the pustule, on the eleventh day, or soon after, is spon- 
taneously broken, and a portion of the matter oozes out ; 
in consequence of which, the pustule is shrivelled, and 
subsides; while the matter oozing out dries, and forms a 
crusts upon its surface. Sometimes a little only of the 
matter oozes out ; and what remains in the pustule be- 
comes thick and even hard. After some days, both the 
crust and the hardened pustules fall off, leaving the skin 
which they covered of a brown red color : and it is only 
after many days that the skin in these places resumes its 
natural color. In some cases., where the matter of the 



PRACTICE OF PHYSIC. 197 

pustules has been more liquid, the crusts formed by it are 
later in falling off, and the part they covered suffers some 
desquamation, which leaves in it a small pit or hollow. 

This is the course of things on the face ; and successively, 
the pustules on the rest of the body take the same. The 
matter of the pustules, on the arms and hands, is frequent- 
ly absorbed; so that, at the height of the disease, these 
pustules appear as empty vesicles. On the tenth and ele- 
venth days, as the swelling of the face subsides, a swelling 
arises in the hands and feet; but which, again, subsides, 
as the pustules come to maturity. 

When the pustules on the face are numerous, some de- 
gree of pyrexia appears on the tenth and eleventh days, 
but disappears again after the pustules are fully ripened ; or 
perhaps remains in a very slight degree till the pustules on 
the feet have finished their course. It is seldom that in the 
distinct small-pox the fever continues longer. 

When the pustules on the face are numerous, some un- 
easiness in the throat, with a hoarseness of the voice comes 
on upon the sixth or seventh day, and a thin liquid is pour- 
ed out from the mouth. These symptoms increase with 
the swelling of the face ; and the liquids of the mouth and 
throat becoming thicker, are more difficultly thrown out. 
There is, at the same time, some difficulty of swallowing; 
so that liquids taken in to be swallowed are frequently re- 
jected or thrown out by the nose. But all these affections 
of the fauces abate as the swelling of the face subsides.* 

589.] In the other form of small-pox, or what is called 
the Confluent, the course of the disease is, in general, the 
same with that we have described ; but the symptoms of 
every stage are more violent, and several of the circum- 
stances are different. 

In particular, the eruptive fever is more violent. The 
pulse is more frequent and more contracted, approaching 
to that state of pulse which is found in the typhus. The 
coma is more considerable, and there is frequently a de- 
lirium. Vomiting, also, is a common symptom, especi- 
ally at the coming on of the disease. In very young in- 
fants, epileptic fits are sometimes frequent on the first days 

* I he discharge of saliva is always salutary, and ought to be moderately encouraged. It is 
probablt owing to the morbific matter attacking the salivary glands, and through them making 
Its exit OUI cit llie body. 

All the affections of the faucet, and the salivation, gradually abate as the swelling of the face 
subsides ; but, u these symptoms disappear suddenly, or are hot succeeded by a swelling of the 
extremities, danger is to be apprehended. 

This remark is solely the remit of experience, and the explanation of it seenn to be involved. 
in considerable difficulty. 

2 c 



198 PRACTICE OF PHYSIC. 

of the disease, and sometimes prove fatal before any 
eruption appears ; or they usher in a very conriuent and 
putrid small-pox. 

590.] The eruption appears more early on the third day, 
and it is frequently preceded or accompanied with an ery- 
sipelatous efflorescence. Sometimes the eruption appears 
in clusters, like that of the measles. When the eruption is 
completed, the pimples are always more numerous upon 
the face, and at the same time smaller and less eminent. Alter 
the eruption, the fever suffers some remission, but never 
goes off entirely ; and, after the fifth or sixth day, it 
again increases, and continues considerable through the re- 
maining course of the disease. 

The vesicles formed on the tops of the pimples appear 
sooner; and while they increase in breadth, do not retain 
a circular, but are every way of an irregular figure. Many 
of them run into one another, insomuch that very often 
the face is covered rather with one vesicle than with a num- 
ber of pustules. The vesicles, so far as they are any-wise 
separated, do not arise to a spheroidical form, but remain 
flat, and sometimes the whole of the face is of an even sur- 
face. When the pustules are in any measure separated, 
their circumference is not bounded by an inflamed mar- 
gin, and the part of the skin that is free from pustules is 
commonly pale and flaccid. 

The liquor that is in the pustules changes from a clear to 
an opaque appearance, and becomes whitish or brownish, 
but never acquires the yellow color and thick consistence 
that appear in the distinct small-pox. 

591 .] The swelling of the face which attends the distinct 
small-pox, when they are numerous, and almost then only, 
always attends the conriuent, comes on more early, and 
arises to a greater degree ; but abates on the tenth day, and 
on the eleventh still more. At this time the pustules or ve- 
sicles break, and shrivelling pour out a liquor that is form- 
ed into brown or black crusts, which do not fall otf for ma- 
ny days after. Those of the face, in falling off, leave the 
parts they cover subject to a desquamation, which pretty 
certainly produces pittings. 

On the other parts of the body, the pustules of the con- 
fluent small-pox are more distinct than upon the face, but 
never acquire the same maturity and consistence of pus as 
in the properly distinct kind. 

The salivation which only sometimes attends the distinct 



PRACTICE OF PHYSIC. 199 

r 

small-pox, very constantly attends the confluent : and both 
the salivation and the affection of the fauces above-mention- 
ed are, especially in adults, in a higher degree. In infants, 
a diarrhoea comes frequently in place of the salivation. 

In the confluent small-pox, there is often a considerable 
putrescency of the fluids, as appears from petechia?, from 
serous vesicles, under which the skin shows a disposition to 
gangrene, and from bloody urine or other haemorrhargy, 
all which symptoms frequently accompany this disease. 

In the confluent small-pox, the fever, which had only suf- 
fered a remission from the time of eruption to that of matu- 
ration, is often, at or immediately after this period, renew- 
ed with considerable violence. This is what has been called 
the Secondary Fever ; and is, in different cases, of various 
duration and event. 

592.] We have thus endeavored to describe the various 
circumstances of the small-pox ; and from the difference of 
these circumstances, the event of the disease may be deter- 
mined. The Avhole of the prognosis may be nearly com- 
prised in the following propositions. 

The more exactly the disease retains the form of the dis- 
tinct kind, it is the safer ; and the more completely the dis- 
ease takes the form of the confluent kind, it is the more 
dangerous. 

It is only when the distinct kind shows a great number of 
pustules on the face, or otherwise, by fever or putrescency, 
approaches to the circumstances of the confluent, that it is 
attended with any danger. 

In the confluent small-pox there is always danger ; and 
this is always more considerable and certain, according as 
the fever is more violent and permanent, and especially as 
the marks and symptoms of putrescency are more evident. 

When the putrid disposition is very great, the disease 
sometimes proves fatal before the eighth day ; but in most 
cases it is on the eleventh that death happens, and some- 
times it is put off till the fourteenth or seventeenth day. 

Though the small-pox should not be immediately fatal, 
the more violent kinds are often followed by a morbid state 
of the body, of various kind and event. These conse- 
quences, as I judge, maybe imputed sometimes to an acrid 
matter produced by the preceding disease, and deposited, 
in different parts ; and sometimes to an inflammatory dia- 
thesis produced, and determined to particular parts ot the 
body. 



200 PRACTICE OF PHYSIC. 

593.] It is, I think, agreed among practitioners, that, 
in the different cases of small-pox, the difference chiefly 
depends upon the appearance of distinct or confluent ; and 
from the above description of these kinds, it will appear, 
that they chiefly differ in the period of the eruption, in the 
number of pustules produced, in the form of the pustules, 
in the state of the matter contained in them, in the conti- 
nuance of the fever, and lastly, in the danger of the disease. 

594.] Upon inquiring into the causes of these differences 
we might readily suspect, that they depended upon a dif- 
ference of the contagion producing the disease. This, 
however, is not probable ; for there are innumerable in- 
stances of the contagion, arising from a person laboring 
under the small-pox of the distinct kind, producing the 
confluent ; and on the contrary. Since the practice of in- 
oculation became frequent, we have known the same vario- 
lous matter produce in one person the distinct, and in ano- 
ther, the confluent small-pox. It is therefore highly pro- 
bable, that the difference of the small-pox does not depend 
upon any difference of the contagion, but upon some dif- 
ference in the state of the person to whom it is applied, or 
in the state of certain circumstances concurring with the 
application of the contagion. 

595.] To find out wherein the difference in the state of 
the persons to Avhom the contagion of the small-pox is ap- 
plied consists, I observe, that the difference between the 
distinct and confluent small-pox consists especially in the 
number of pustules produced ; which, in the distinct, are 
generally few, in the confluent, always many. If, there- 
fore, we shall be able to discover what, in the state of dif- 
ferent persons, can give occasion to more or fewer pustules, 
we shall probably be able to account for all the other dif- 
ferences of the distinct and confluent small-pox. 

596.] It is evident, that the contagion of the small- pox 
is a ferment with respect to the human fluids, and assimi- 
lates a great part of them to its own nature ;* and it is pro- 
bable, that the quantity thus assimilated, is, in proportion 
to the bulk of their several bodies, nearly the same in dif- 
ferent persons. This quantity passes again out of the body, 

* This opinion is most probably true, but it is by no means, as the author says, evident. Hit 
reasoning, however, is ingenious and deserves attention. The expulsion, or rather evacuation 
of the morbific matter is admitted as the cure of the disease, and the difference of the disease to 
the different manner in which this evacuation is made: But, the author has not proved cither 
of the premises he has advanced, viz. thai the quantity of human fluids which the ferment as- 
similates, is nearly the same in different persons, nor that any part of the morbtiie matter, or 
the morbid assimilated fluids pass off by perspiration. 



PRACTICE OF PHYSIC. 2 0l 

partly by insensible perspiration, and partly by being depo- 
sited in pustules ; but if the quantities generated be nearly 
equal, the quantities passing out of the body by the two 
ways mentioned, are very unequal in different persons ; and, 
therefore, if we can explain the causes which determine 
more to pass by the one way than by the other, we may 
thereby discover the causes which give occasion to more pus- 
tules in one person than in another. 

597.] The causes which determine more of the variolous 
matter to pass by perspiration, or to form pustules, are 
probably certain circumstances of the skin, that determine 
more or less of the variolous matter to stick in it, or to pass 
freely through it. 

598.] The circumstance of the skin, which seems to de- 
termine the variolous matter to stick in it, is a certain state 
of inflammation depending, much upon the heat of it. 
Thus we have many instances of parts of the body, from 
being more heated, having a greater number of pustules 
than other parts. In the present practice of inoculation, 
in which few pustules are produced, much seems to be ow- 
ing to the care that is taken to keep the skin cool. Parts 
covered with plaisters, especially with those of a stimulant 
kind, have more pustules than other parts. Further, cer- 
tain circumstances, such as adult age, and full living, deter 
mining to a phlogistic diathesis, seem to produce a greater 
number of pustules j while the contrary circumstances have 
contrary effects. 

599.] It is therefore probable, that an inflammatory state 
of the whole system, and more particularly of the skin, 
gives occasion to a greater number of pustules : and the 
causes of this may likewise produce most of the other cir- 
cumstances of the confluent small-pox ; such as the period 
of eruption ; the continuance of the fever ; the effusion of 
a more putrescent matter, and less fit to be converted into 
pus ; and, what arises from thence, the form and other 
circumstances of the pustules. 

600.] Having thus attempted to account for the chief 
difference which occurs in the state of the small-pox, we 
shall now try the truth of our doctrine, by its application 
to practice. 

601.] In considering the practice, we view it first, in 
general, as suited to render the disease more generally be- 
nign and safe, and this by the practice of inoculation. 

602.] It is not necessary here to describe the operation 



202 PRACTICE OF PHYSIC. 

of inoculating ; and what we name the practice of inocu- 
lation, comprehends all the several measures which precede 
or follow that operation, and are supposed to produce its 
salutary effects. 

These measures are chiefly the following. 

1. The choosing for the subject of inoculation persons 
Otherwise free from disease, and not liable, from their age 
or other circumstances, to any incidental disease. 

2. The choosing a person at the time of life most favor- 
able to a mild disease. 

3. The choosing for the practice a season the most con- 
ducive to the mildness of the disease. 

4. The preparing the person to be inoculated, by absti- 
nence from animal food for some time before inoculation. 

5. The preparing the person by courses of mercurial 
and antiinonial medicines.* 

6. The taking care, at the time of inoculation, to avoid 
cold, intemperance, fear, or other circumstances which 
might aggravate the future disease. 

7. After these preparations and precautions, the choos- 
ing a fit matter to be employed in inoculation, by taking 
it from a person of a sound constitution, and free from any 
disease or suspicion of it ; by taking it from a person who 
has had the small-pox of the most benign kind ; and, lastly, 
by taking the matter from such persons, as soon as it has 
appeared in the pustules, either in the part inoculated, or 
on other parts of the body. 

8. The introducing, by inoculation, but a small portion 
of the contagious matter. 

9. After inoculation, the continuing the vegetable diet, 
as well as the employment of mercurial and antimonial 
medicines ; and, at the same time, frequently employing 
purgatives. 

10. Both before and after inoculation, taking care to 
avoid external heat, either from the sun, artificial fires, 
warm chambers, much clothing, or being much in bed ; 
and, on the contrary, exposing the person to a free and 
cool air. 

1 1. Upon the appearance of the eruptive fever, the ren- 
dering that moderate by the employment of purgatives ; by 
the use of cooling and antiseptic acids ; and especially by 
exposing the person frequently to a cool and even a cold air, 
at the same time giving freely of cold drink. 

* Compare this paragraph with what follows in article 608. 



PRACTICE OF PHYSIC. 20S 

12. After the eruption, the continuing the application 
of cold air, and the use of purgatives, during the course 
of the disease, till the pustules are fully ripened. 

603.] These are the measures proposed and practised in 
the latest and most improved state of inoculation ; and the 
advantages obtained by the whole of the practice, or at least 
by most of the measures above mentioned, are now ascer- 
tained by a long experience to amount to this, That, in 
ninety-nine cases of the hundred, inoculation gives a dis- 
tinct small-pox only, and that also very generally of the 
mildest form ; but it will still be useful, for the proper 
conduct of inoculation, to consider the importance and 
utility of the several measures above mentioned, that we 
may thereby more exactly determine upon what the advan- 
tages of inoculation more certainly depend. 

604.] As the common infection may often seize persons 
laboring under another disease, which may render the 
small-pox more violent, it is obvious that inoculation must 
have a great advantage, by avoiding such concurrence. 
But as the avoiding such concurrence may often, in the 
mean while, leave persons exposed to the common infec- 
tion, it merits inquiry, whether every diseased state should 
restrain from the practice of inoculation, or what are the 
particular diseases that should do so. This is not yet suf- 
ficiently ascertained by observation ; and we have fre- 
quently remarked that the small-pox have often occurred 
with a diseased state of the body, without being thereby 
rendered more violent. In particular, we have observed, 
that a scrophulous habit, or even the presence of scrophula, 
did not render the small-pox more violent ; and we have 
observed also, that several diseases of the skin are equally 
innocent. I am of opinion, that they are the diseases of the 
febrile kind, or ailments ready to induce or aggravate a 
febrile state, that especially give the concurrence which is 
most dangerous with the small-pox. I dare not attempt 
any general rules; but 1 am disposed to maintain, that 
though a person be in a diseased state, if that state be of 
uncertain nature and effect, and at the same time the small- 
pox be exceedingly rife, so as to render it extremely diffi- 
cult to guard against the common infection, it will always 
be safer to give the small-pox by inoculation, than to leave 
the person to take them by the common infection. 

605.] Though inoculation has been practised with safety 
upon persons of all ages; yet from what has actually oc- 



204 PRACTICE OF PHYSIC. 

curred in the cases of common infection, and from sever- 
al other considerations, there is reason to conclude that 
adults are more liable to a violent disease than persons of 
younger years. At the same time, it is observed that 
children, in the time of their first dentition, are liable 
from this irritation, to have the small-pox rendered more 
violent ; and that infants, before the time of dentition 
upon receiving the contagion of the small-pox, are liable 
to be affected with epileptic fits, which frequently prove 
fatal. It is, therefore, upon the whole, evident, that 
though circumstances may admit, and even render inocu- 
lation at any age proper; yet, for the most part, it will be 
still more advisable to choose persons at an age, after the 
first dentition is over and before the time of puberty. 

606.] Though inoculation has been practised with safe- 
ty at every season of the year ; yet, as it is certain that the 
cold of winter may increase the inflammatory, and the 
heats of summer increase the putrescent state of the small- 
pox, it is highly probable that inoculation may have some 
advantage, from avoiding the extremes, either of heat or 
cold. 

607.] Although the original temperament and constitu- 
tions of men are not to be readily changed ; it is sufficient- 
ly certain, that the conditions of the human body may, by 
various causes, in many respects be occasionally very much 
changed ; and therefore, as the use of animal food may 
increase both the inflammatory and putrescent state of the 
human body T , so it must render persons, on receiving 
the contagion of the small-pox, less secure against a vio- 
lent disease; and, therefore, inoculation may derive some 
advantage from abstinence from animal food, for some 
time before the inoculation is performed: but I am of opi- 
nion that a longer time than that usually prescribed may be 
often necessary; and I am persuaded, that the Scottish 
mothers who avoid giving their children animal food till 
they are past the small-pox, render this disease in them 
of a milder kind. 

60S.] I cannot deny that mercurial and antimonial me- 
dicines may have some effect in determining to a more free 
perspiration, and therefore may be of some use in prepar- 
ing a person for the small-pox ; but there are many obser- 
vations which render me doubtful as to their effect. The 
quantity of both these medicines, particularly of the an- 
timony, commonly employed, is too inconsiderable to pro- 



PRACTICE OF PHYSIC. 2 05 

duce any effect. It is true, that the mercurials have often 
been employed more freely ; but even their salutary effects 
have not been evident, and their mischievous effects, have 
sometimes appeared. I doubt, therefore, upon the whole, 
if inoculation derives any advantage from these pretended 
preparatory courses of medicines. 

609.] As it has been often observed, in the case of al- 
most all contagions, that cold, intemperance, fear, and 
some otber circumstances, concurring with the application 
of the contagion, have greatly aggravated the future disease, 
so it must be the same in the case of the small-pox ; and it 
is undoubted, that inoculation must derive a great, and 
perhaps its principal, advantage, from avoiding the con- 
currences above mentioned. 

610.] It has been commonly supposed, that inoculation 
has derived some advantage from the choice of the matter 
employed in it; but, from what has been observed in 594, 
it must appear very doubtful if any choice be necessary, 
or can be of any benefit in determining the state of the 
disease.* 

611.] It has been supposed by some, that inoculation has 
an advantage, by introducing a small portion only of the 
contagious matter: but this rests upon an uncertain foun- 
dation. It is not known what quantity is introduced by the 
common infection, and it may be a small quantity only. 
Although it were larger than that thrown in by inoculation, 
it is not ascertained that the circumstance of quantity 
would have any effect. A certain quantity of ferment may 
be necessary to excite fermentation in a given mass: but 
that quantity given, the fermentation and assimilation are 
extended to the whole mass; and we do not find that a 
greater quantity than is just necessary, either increases the 
activity of the fermentation, or more certainly secures the 
assimilation of the whole. In the case of the small-pox, a 
considerable difference in the quantity of contagious mat- 
ter introduced, has not discovered any effect in modifying 
the disease. 

612.] Purging has the effect of diminishing the activity 
of the sanguiferous system, and of obviating its inflamma- 
tory state. It is therefore probable, that the frequent use 
of cooling purgatives is a practice attending inoculation 
which may be of considerable advantage; and, probably, 

• To romovc all suspicion, however, it is doubtless better to inoculate with matter taken from 
a uiiul state of the disease. 

2d 



206 PRACTICE OF PHYSIC. 

it is also useful by diminishing the determination to the * 
skin. It appears to me, that mercurials and antimonials. 
as they are commonly managed, are useful only as they 
make a part of the purging course.* 

613.]- It is probable, that the state of the small-pox de- 
pends very much upon the state of the eruptive fever, and 
particularly upon moderating the inflammatory state of 
the skin; and, therefore, it is probable, that the measures 
taken for moderating the eruptive fever and inflammatory 
state of the skin, afford the greatest improvement which 
has been made in the practice of inoculation. The ten- 
dency of purging, and the use of acids for this purpose, is 
sufficiently obvious ; and upon the same ground, we should 
suppose, that blood-letting might be useful; but probably 
this has been omitted, for the same reason that might per- 
haps have led to the omission of other remedies also; which 
is, that we have found a more powerful and affectual one 
in the application of cold air, and the use of coJd drink. 
Whatever doubts or difficulties our theory might present 
to us on this subject, they may be entirely neglected, as 
the practice of Indostan had long ago, and the practice of 
this country has lately, by a large and repeated experience, 
ascertained the safety and efficacy of this remedy: and as 
it may and can be more certainly employed with the prac- 
tice of inoculation, than it can be in cases of common in- 
fection, it must give a singular advantage to the former.f 
614.] After the eruption, when a few pimples only have 
appeared on the face, the continuing the application of cold 

* All purges are extremely nauseous to children; and as it is of little consequence what purga- 
tives we use, if we only avoid the hot drastic stimulants, we ought to pay attention to the agree- 
ableness of the form. Children may in general be deceived by the following device : Put half 
an ounce of senna leaves (after the stalks are all picked out) into a tea-pot, with a quarter of 
an ounce of green tea ; pour on it a quart of boiling water. Let the child see it poured out 
into a tea-cup, sweetened with plenty of moist sugar, and cream put to it. The child will drink 
it with avidity. A tea-cupful may be given every hour till it begin to operate. 

If this divice should fail a second time, another maybe used in its stead. Two drachms of 
senna leaves, powdered, may be added to half a pound of ginger-bread paste; the mass may 
be divided into fifteen small cakes to be baked : give the child one of these cakes every half 
hour till it begins to operate, or till he has taken a sufficient dose for his age. A drachm of jalap 
may be used inslead of the senna. 

It neither of the;e artifices succeed, a dose of powdered senna, with or without a little gin- 
ger, may be given in orange marmalade. 

Children will sometimes eat as many tamarinds as will sufficiently answer all the intentions of 
a formal purge. A luile Cassia-pulp, added lo the tamarinds, will inciease their activity, and 
will not be easily perceived by t'ne child. . 

The empirics have committed many strange chemical blunders in compounding their purges 
for inoculation. Dimsdale'S powder, may serve as an example : it consists of tartar emetic, and 
crabs claws. The calcareousearth deprives the tartar emetic of itsacid ; in consequence of which, 
the antimony will be inert, except it accidentally meets with an acid in the stomach ; and even 
then the acid must be in such a quantity as to saturate the crabs claws, before it can acton the 
antimonial calx. 

4- Notwithstanding the justness of ihis remark, bleeding ought not to be employed, except 
in cases where the phlogistic diathe.-is and s; mptoros are violent: the flight which children suf- 
fer in consequence of die operation, may be productive of much mischief ; and purgatives, 
when properly administered, supersede the necessity of bleeding, especially when the cold re- 
jimen is employed at the same tune. 



PRACTICE OF PHYSIC. 207 

air, and the employment of purgatives, has indeed been 
the practice of many inocnlators : but I think, these prac- 
tices cannot be said to give any peculiar advantages to ino- 
culation ; for when the state of the eruption is determined, 
when the number of pustules is very small, and the fever 
has entirely ceased, I hold the safety of the disease to 
be absolutely ascertained, and the further use of remedies 
entirely superfluous. In such cases, I judge the use of pur- 
gatives to be not onty unnecessary, but that they may be 
often hurtful. 

615.] I have thus considered the several circumstances 
and practices accompanying inoculation, and have endea- 
vored to ascertain the utility and importance of each. Up- 
on the whole, I hope I have sufficiently ascertained the ge- 
neral utility and great advantage of this practice, especi- 
allv consisting in this, that if certain precautions, prepa- 
rations, and remedies, are of importance, all of them can 
be employed with more certainty in the practice of inocu- 
lation, than in the case of common infection.* 

It remains now that I should offer some remarks on the 
conduct of the small-pox, as received by infection, or even 
when, after inoculation, the symptoms shall prove violent. 
The latter sometimes happens, although every precaution 
and remedy have been employed. The cause of this is 
not well known ; but it appears to me to be commonly 
owing to a disposition of the fluids to putrescency. But, 
however this may be, it will appear, that, not only in the 
case of common infection, but even in that of inoculation, 
there may be occasion for studying the conduct of this 
disease, in all its possible varying circumstances. 

616.] When, from the prevailing of small-pox as an epi- 
demic, and more especially when it is known that a person 
not formerly affected with the disease has been exposed to 
the infection, if such person should be seized with the symp- 
toms of fever, there can be little doubt of its being an at- 
tack of the small-pox ; and therefore he is to be treated in 
every respect as if the disease had been received by inocu- 

* The author seems to have forgotten a frequent consequence of inoculation, that demands 
some attention, viz. an inti.immation of the axillary glands, that often terminates in suppura- 
tion. Many <• lses of this kind occurred to me in practice, and I attempted several methods of 
preventing the suppuration ; of whiab I found the following the most efficacious : If only one 
arm had oeen punctured, the gland of that arm, when such an accident happened, and not of 
the other, was inttamed. In attempting the resolution, which perhaps some practitioners may 
think improper, I applied cold compresses, impregnated with a solution of Saccharum Saturin, 
to the inflamed eland, and a warm poultice to the ulcer of the puncture. The consequence 
was an increased discharge from the puncture, and a diminution of the axillary swelled gland. 

No ill consequences attended any of those cases where the tumor was thus resolved; but when 
these tumors luppujatc, Uiey are apt to produce siuous ulcere, very difficult to heal. 



208 PRACTICE OF PHYSIC. 

lation. He is to be freely exposed to a cool air, to be 
purged, and to have cooling acids given HberalK 

617.] If these measures moderate the. lever, nothing 
more is necessary : but if the nature of the fever attacking 
a person be uncertain ; or if, with suspicions of the small- 
pox, the symptoms of the fever be violent : or even if, 
knowing the disease to be small-pox, the measures men- 
tioned (596.) shall not moderate the fever sufficiently ; it 
will be proper to let some blood : and this will be more 
especially proper, if the person be an adult, of a plethoric 
habit, and accustomed to full living. f 

618.] In the same circumstances, we judge it will be 
always proper to give a vomit, as useful in the commence- 
ment of all fevers, and more especially in this, where a 
determination to the stomach appears from pain and spon- 
taneous vomiting. 

619.] It frequently happens, especially in infants, that 
during the eruptive fever of the small-pox, convulsions 
occur. Of these, if only one or two fits appear on the 
evening preceding the eruption, they give a favorable prog- 
nostic of a mild disease, and require no remedy ; but if 
they occur more early, and be violent and frequently re- 
peated, they are very dangerous, and require a speedy re- 
medy. For this purpose, bleeding is hardly ever of service; 
blistering always comes too late ; and the only remedy I 
have found effectual, is an opiate given in a large dose. J 

620.] These are the remedies necessary during the erup- 
tive fever ; and if, upon the eruption, the pimples upon 
the face be very few and distinct, the disease is no further 
of any dinger, requires no remedies, and the purgatives, 
which, as has been said before, are by some practitioners 
continued, prove often hurtful. 

But when, upon the eruption, the pimples on the face are 
very numerous ; when they are not distinct ; and especially 
when, upon the fifth day, the fever does not suffer a consi- 
derable remission, || the disease will still require a great deal 
of attention. 

* The cooling acids have been described in former notes, (Art. 151. and 134.) Whey made 
with cream of tartar is very useful in the binail-pox, as it is a cooling drink, and at the 
time laxative. It is made by throwing into a quart ot boiling rank half an ounce or six drachms 
of powdered cream of tartar. 

+ This practice ;-. most judicious, and ou^ht to be strictly followed. 

j The doses for children mthesecases are as follows: A child of half a year, five drops of 
laudanum : From half a year to a year, six drops : From one to two years, seven or eight : From 
two to three, nine Often: Five years, twelve, or at most fitteer.. These are laige doses, and 
are such as are only to be given to robust children. 

!: Tne practitioner ouaht to l>e particularly attentive to the sympioms which appear on the 
fifth day. The subsequent paragraphs lender any tarlher remarks needless. 



PRACTICE OF PHYSIC. 209 

621.] If, after the eruption, the fever shall continue ; the 
avoiding heat, and continuing to expose the body to a 
cool air, will still be proper. If the fever be considerable, 
with a full and hard pulse, in an adult person, a bleeding 
will be necessary; and, more certainly, a cooling purgative. 
It is, however, seldom that a repetition of the bleeding will 
be proper, as a loss of strength does usually come on very 
soon ; but the repetition of a purgative, or the frequent use 
of laxative glysters, is commonly useful.* 

622.] When a loss of strength, with other marks of a 
putrescent tendency of the fluids, appears, it will be ne- 
cessary to exhibit the Peruvian bark in substance, and in 
large quantity. f In the same case, the free use of acids, 
and of nitre, X is useful ; and it is commonly proper also to 
give wine very freely. || 

623.] From the fifth day of the disease, onward through 
the whole course of it, it is proper to give an opiate once or 
twice a day ; taking care, at the same time, to obviate cos- 
tiveness, by purgatives, or laxative glysters. 

624.] In a violent disease, from the eighth to the ele- 
venth day, it is proper to lay on blisters successively on dif- 
ferent parts of the body ; and that without regard to the 
parts being covered with pustules. 

625.] If, in this disease, the tumor of the fauces be con- 
siderable ; the deglutition difficult ; the saliva and mucus 
viscid, and with difficulty thrown out ; it will be proper to 
apply blisters to the external fauces, and to employ dili- 
gently detergent gargles. § 

626.] During the whole course of the disease, when any 

* Laxative glysters are preferable to repeated purgatives, on account of their not debilitating 
the patient so much as purgatives. The following fotin has been found very effectual: 

R. Fol. Sennae, §ft. 

Sal. cathartic, amar. 3*i. 
Aq. bullient. lb. i. 
Colaturae frigidae adde. 
Syr. e Spin. Cervin. §i. 
01. Olivar. 3 Ji- 
M. 

Or even a simple solution ol Kpsom salt in warm water. 

+ The method of giving the bark in the small-pox, is the same 'with that mentioned in the 
I ;i7. For children, the glyster there mentioned, is extremely convenient, and 

onderfully efficacious 

\ in 1 uulcis is the best torm in which nitre can be given to children. See the 
notes on article 111. 

II The wine best suited to these cases is Purt wine : but as children sometimes loath it, g«od 
Clare) ma) be lubstituted in its place. 

;argles in tin, case .ire the tincture of roses with honey ; or the -jarijie of 
■ ir and honey, mentioned in the note on article J17; 01 Dr. lotlier- 
jilt'j gargle described in that uole. 



«10 PRACTICE OF PHYSIC. 

considerable fever is present, the frequent exhibition of an- 
tiuionial medicines, in nauseating doses, has been found 
useful ;* and these, for the most part, sufficiently answer 
the purpose of purgatives. 

627.] The remedies mentioned from 621. to 625. are 
those frequently necessary, from the fifth day, till the sup- 
puration is finished. But as, after that period, the fever is 
sometimes continued and increased; or, as sometimes, 
when after there has been little or no fever before, a fever 
now arises, and continues with considerable danger ; this is 
what is called the Secondary Fever, and requires particular 
treatment. 

628.] When the secondary fever follows the distinct small- 
pox, and the pulse is full and hard, the case is to be treat- 
ed as an inflammatory affection, by bleeding and purging. 
But, if the secondary fever follow the confluent small-pox, 
and be a continuance or exacerbation of the fever which 
had subsisted before, it is to be considered as of the putrid 
kind ; and in that case, bleeding is improper. Some purg- 
ing may be necessary ; but the remedies to be chiefly de- 
pended on, are the Peruvian bark and acids.f 

When the secondary fever first appears, whether it is af- 
ter a distinct, or confluent small-pox, it will be useful to ex- 
hibit an antimonial emetic in nauseating doses, but in such 
a manner as to produce some vomiting. 

629.] For avoiding the pits which frequently follow the 
small-pox, many different measures have been proposed ; 
but none of them appear to be sufficiently certain.! 

* A solution of two grains of emetic tartar in eight ounces of water answers this intention 
very effectually. The dose is to he determined by the nauseating eflect produced : a table- 
spoonful of the solution may be given occasionally every two or three hours. Care, however, 
must be taken, that vomiting is not produced : and, at the same time, a sufficient quantity 
must be given to produce a nausea. Both these circumstances depend on the age, strength, and, 
constitution of the patient and on the violence of the disease. 

+ The secondary fever is always the worst, and most dangerous stage of the disease. In the 
distinGt small pox it seldom occurs; but it is a constant attendant on the confluent kind. It 
seems to be owing to the absorption of the matter : foi it never appears, evidently at least, till 
after the suppuration : and, ceteris paribus, it is always more violent in proportion to the quan- 
tity of pustules. Some authors recommend opening the pustules, in order to evacuate the 
matter, as a preventative against the secondary fever; and when the eruption is large, this 
practice is advisable. 

The Peruvian bark must be given in these cases in the largest quantities that the stomach can 
bear, aid also in glysters as formerly mentioned. Some practitioners, beside the internal use of 
bark, and giving it in glysters, have advised it to be applied externally by throwing the dry 
powder on those parts of the body that are the most exulcerated. 

X The most effectual means of preventing pits, are to avoid much exposure to the cold air, 
to anoint the face with oil, &x. 



PRACTICE OF PHYSIC. i\ i 



CHAPTER II. 
OF THE CHICKEN-POX. 

630.] nr^HIS disease seems to depend upon a specific 
JL contagion, and to affect persons but once in 
their lives. It is hardly ever attended with any danger ; but 
as it seems frequently to have given occasion to the suppo- 
sition of a person's having the small-pox twice, it is proper 
to study this disease, and to distinguish it from the genu- 
ine small-pox.* 

631.] This may be generally done by attending to the 
following circumstances. 

The eruption of the chicken-pox comes on with very 
little fever preceding it, or with fever of no determined 
duration. 

The pimples of the chicken-pox, more quickly than 
those of the small-pox, are formed into little vesicles or 
pustules. 

The matter in these pustules remains fluid, and never ac- 
quires the color or consistence of the pus which appears in 
the pustules of the small-pox. 

The pustules of the chicken-pox are always in three or 
four days from their first appearance, formed into crusts. 

See Dr. Heberden in Med. Transact. Vol. I. art. xvii. 



CHAPTER III. 

OF THE MEASLES. 

632.] r I ^HIS disease also depends upon a specific con- 
-L tagion, and affects persons but once in their 
lives. 

633.] It occurs most frequently in children ; but no age 
is exempted from it, if the persons have not been sub- 
jected to it before. 

634.] It commonly appears as an epidemic, first in the 
month of January, and ceases soon after the summer sol- 

• As this disease is generally mild, and scarcely ever requires the assistance of art in the cure, 
the author very properly passes it over in a cursory manner. It sometimes, however, very 
| the mild small pox ; and in >uch cases may require the treatment which has been 
recommended as serviceable in that disease. 



212 PRACTICE OF PHYSIC. 

stice ; but various accidents, introducing the contagion, 
may produce the disease at other times of the year. 

635. J The disease always begins with a cold stage, 
which is soon followed by a hot, with the ordinary symp- 
toms of thirst, heat, anorexia, anxiety, sickness, and vo- 
miting ; and these are more or less considerable in diffe- 
rent cases. Sometimes from the beginning, the fever is 
sharp and violent ; often, for the first two days, it is ob- 
scure and inconsiderable, but always becomes violent be- 
fore the eruption, which usually happens upon the fourth 
day. 

636.] This eruptive fever from its commencement, is 
always attended with hoarseness, with a frequent hoarse dry 
cough, and frequently with some difficulty of breathing. 
At the same time, the eye-lids are somewhat swelled, the 
eyes are a little inflamed, and pour out tears ; and, to- 
gether, with these symptoms, there is a coryza, and fre- 
quent sneezing. For the most part, a constant drowsi- 
ness attends the beginning of this disease. 

637.] The eruption, as we have said, commonly ap- 
pears upon the fourth day, first on the face, and succes- 
sively on the lower parts of the body. It discovers itself 
first in small red points ; but, soon after a number of these 
appear in clusters, which do not arise into visible pimples, 
but by the touch are found to be a little prominent. This 
is the case on the face ; but on other parts of the body, 
the prominence, or roughness, is hardly to be perceived. 
On the face the eruption retains its redness, or has that in- 
creased for two days : but, on the third, the vivid redness 
is changed to a brownish red ; and, in a day or two more, 
the eruption entirely disappears, while a meally desqua- 
mation takes place. During the whole time of the erup- 
tion, the face is somewhat turgid, but seldom considera- 
bly swelled. 

638.] Sometimes, after the eruption has appeared, the 
fever ceases entirely : but this is seldom the case ; and 
more commonly the fever continues, or is increased after 
the eruption, and does not cease till after the desquama- 
tion. Even then the fever does not always cease, but 
continues with various duration and effect. 

639.] Though the fever happen to cease upon the erup- 
tion's taking place, it is common for the cough to continue 
till after the desquamation, and sometimes much longer. 

In all cases, while the fever continues, the cough also 



PRACTICE OF PHYSIC. 213 

continues, generally with an increase of the difficulty of 
breathing; and both of these symptoms sometimes arise to 
a degree that denotes a pneumonic affection. This may 
arise at any period of the disease ; but very often it does 
not come on till after the desquamation of the eruption. 

After the same period, also, a diarrhoea frequently 
comes on, and continues for some time. 

640.] It is common for the measles, even when they 
have not been of a violent kind, to be succeeded by in- 
flammatory affections, particularly opthalmia and phthisis. 

641.] If the blood be drawn from a vein during the' 
measles, with the circumstances necessary to favor the se- 

{>aration of the gluten, this always appears separated, and 
ying on the surface of the crassamentum, as in inflam- 
matory diseases. 

642.] For the most part, the measles, even when vio- 
lent, are without any putrid tendency ; but in some cases, 
such a tendency appears, both in the course of the dis- 
ease, and especially after the ordinary course of it is fi- 
nished. See Dr. Watson, in London Med. Observations, 
Vol. IV. art. xi. 

643.] From what is delivered, from 636, to 641, it will 
appear, that the measles are distinguished by a catarrhal 
affection, and by an inflammatory diathesis to a considera- 
ble degree, and therefore the danger attending them arises 
chiefly from the coming on of a pneumonic inflammation. 

644.] From this consideration it will be obvious, that 
the remedies especially necessary, are those which may 
obviate and diminish the inflammatory diathesis ; and 
therefore, in a particular manner, blood-letting. This re- 
medy may be employed at any time in the course of the 
disease, or after its ordinary course is finished. It is to be 
employed more or less according to the urgency of the 
symptoms of fever, cough, and dyspnoea ; and generally 
may be employed very freely.* But, as the symptoms 
of pneumonic inflammation seldom come on during the 
eruptive fever ; and, as this fever is sometimes violent im- 
mediately before the eruption, though a sufficiently mild 
disease be to follow ; so bleeding is seldom very necessa- 
ry during the eruptive fever, and may often be reserved 
for the periods of greater danger which perhaps are to 
ensue. 

* (Heeding ought to be used where it is absolutely necessary ; but, too free a use - 
keen attended with a long continued weakness, and a v«ry slow recovery. 

2 £ 



214 PRACTICE OF PHYSIC. 

645.] In all cases of measles, where there are no marks 
of putrescency, and where there is no reason, from the 
known nature of the epidemic, to apprehend putrescency, 
bleeding is the remedy to be depended upon ; but assist- 
ance may also be obtained from cooling purgatives ; and 
particularly from blistering on the sides, or between the 
shoulders. 

646.] The dry cough may be alleviated by the large use 
of demulcent pectorals, mucilaginous, oily, or sweet.* 
It may, however, be observed, with respect to these de- 
mulcents, that they are not so powerful in involving and 
correcting the acrimony of the mass of blood as has been 
imagined ; and that their chief operation is by besmearing 
the fauces, and thereby defending them from the irritation 
of acrids, either arising from the lungs, or distilling from 
the head. 

647.] For moderating and quieting the cough in this 
disease, opiates certainly prove the most effectual means, 
whenever they can be safely employed. In the measles, 
in which an inflammatory state prevails in a considerable 
degree, opiates may be supposed to be inadmissible ; and, 
in those cases in which a high degree of pyrexia and dysp- 
noea show either the presence, or at least the danger, of 
pneumonic inflammation, I think that opiates might be 
very hurtful. In cases, however, in which the dyspnoea 
is not considerable, and where bleeding, to obviate or abate 

* Two ounces of pearl bailey, and four ounces of dried figs, cut, boiled in a gallon of water 
to three quarts, is a good drink in these cases. If the patient loaths this drink, hniseed tea, .or 
a slight infusion of Orrice root in boi.ing water, may be substituted in its place, or a solution 
of an ounce of gum arabic in a point of water. 

Oily emul.ions are also recommended ; the most useful is the following : 

R. 01. Amygdal. §ii. 
Aq. Font. §vi. 

Alkali Caustic, q. s. ut fiat Emuls. cui adde 
Syrup. Althaeas, gii. 

The patient may take half a tea-cupful of this emulsion occasionally, when the cough is most 
ttoublesome. The cough may also be relieved, by taken now and then a tea-spoonful of tfw: 
following Linctus: 

R. 01. Amygdal. 
Syrup. Althaea. 
Conserv. Cynosbat. aa. §i. 
M. f. Linct. 

Or the following : 

R. Mel. anglic. 

01. Amygdal. aa. sir. 
Succ. Limon. si. 
#T, f. Linct. 



PRACTICE OF PHYSIC. 215 

the inflammatory state, has been duly employed, and 
where the cough and watchfulness are the urgent symp- 
toms, I think that opiates may be safely exhibited, and 
with great advantage.* I think, further, that, in all the 
exanthemata, there is an acrimony diffused over the sys- 
tem, which gives a considerable irritation ; and, for obvi- 
ating the effects of this, opiates are useful, and always 
proper, when no particular contra-iudication prevails. 

648.] When the desquamation of the measles is finished, 
though there should then be no disorder remaining, phy- 
sicians have thought it necessary to purge the patient sev- 
eral times, with a view to draw off the dregs of this dis- 
ease, that is, a portion of the morbific matter which is sup- 
posed to remain long in the body. I cannot reject this 
supposition; but, at the same time, cannot believe, that 
the remains of the morbific matter, diffused over the whole 
mass of blood, can be entirely drawn off by purging; and 
it appears to me, that to avoid the consequences of the 
measles, it is not the drawing off the morbific matter which 
we need to study, so much as the obviating and removing 
the inflammatory state of the system which had been in- 
duced by the disease. With this last view, indeed, purg- 
ing may still be a proper remedy ; but bleeding, in pro- 
portion to the symptoms of inflammatory disposition, is 
yet more so.f 

649.] From our late experience of the benefit of cold 
air in the eruptive fever of the small-pox, some physicians 
have been of opinion, that the practice might be transfer- 

* Opiates, in all inflammatory cases, ought to be cautiously used. The danger arising from 
them is considerably obviated, by using only the gummy part of the opium, and therefore the 
watery solution of opium, is in these cases preferable to any other form. 

rupus papaveris albi, ii an opiate peculiarly adapted to this disease; the doseof.it is 
immaterial, provided we do not exceed four ounces in the four and twenty hours; a tahle- 
spoonful may he taken when the cough is troublesome, and may be repeated every two or three 
hours according to the urgency of the symptoms. 

+ The complaints which the measles leave are chiefly pneumonic. The cough is the most 
troublesome symptom, and to relieve the patient from it. not only bleeding and purging must 
be used, but expectorants ought also to be administered. The Lac Aminoniacum, formerly 
mentioned, has often proved beneficial. 

on the supposition, that the cough and pneumonic affection remaining after the measles are 
owing to a peculiar acrimony, some practitioners have recommended alteratives and demul- 
cents: I iweyer, has found little advantage from their use. I once saw a body 
Opened) that had died thirty-two days after the eruption: the internal surface of the bronchia? 
ill tursuraceous scales, somewhat like those that appear on the skin when 
the eruption goes off. Hence 1 have been induced to suppose, that expectorants are the best 
remedies in these i ases, and indeed, experience confirms the practice. Bleeding and purging 
are oni, i prevent the inflammation. 

od of avoiding the ill consequences that follow the disease, is a free use of de- 
drinks, during the eruption, and of expectorants immediately after it. The Decoctuin 
nun, ot the London Pharmacopoeia, is peculiarly adapted to these cases, but it 
is much i ■ root, when it is nearly boiled en 

the 01 rice be added' too soon , the efficacious part of ii evaporates. The Lac Ammoi 
above mentioned, is a verj proper expectorant, but if it should pn 

bj the patient, recourse may be had to the w«»k solution •!' the tartar emetii ~o 
•/ten mentioned in these notes. 



216 PRACTICE OF PHYSIC. 

red to the measles ; but we have not yet had trials sufficient 
to ascertain this. 

There is no doubt that external heat may be very hurtful 
in the measles, as in most other inflammatory diseases; 
and therefore the body ougbt to be kept in a moderate tem- 
perature during the whole course of the measles ; but how 
far, at any period of the disease, cold air may be applied 
with safety, we are yet uncertain. Analogy, though so 
often the resource of physicians, is, in general, fallacious; 
and further, though the analogy with the small-pox might 
lead to the application of cold air during the eruptive fever of 
the measles, the analogy with catarrh seems to be against the 
practice. After the eruption had appeared upon the skin, 
we have had many instances of cold air making it disap- 
pear, and thereby producing much disorder in the system; 
and have also had frequent examples of such disorder be- 
ing removed by restoring the heat of the body, and there- 
by again bringing forth the eruption.* 



CHAPTER IV. 
OF THE SCARLET FEVER. 

650.] TT may be doubted if the scarlet fever be a dis- 
X ease specifically different from the Cynanche 
Maligna above described. The latter is almost always at- 
tended with a scarlet eruption ; and, in all the instances I 
have seen of what may be called the scarlet fever, the dis- 
ease, in almost every person affected, has been attended 
with an ulcerous sore, throat. 

651.] This view of the matter may create some doubt ; 
but I am still of opinion, that there is a scarlet fever which 
is a disease specifically different from the Cynanche Ma- 
ligna. 

Dr. Sydenham has described a scarlet fever, which he 
had seen prevailing as an epidemic, with all the circum- 
stances of the fever and eruption, Avithout its being accom- 
panied with any affection of the throat; at least he does 
not take notice of any such affection, which such an accu- 
rate observer could not fail to have done, if any such 
symptom, as we have commonly seen making a principal 

* Though the application of cold air be dangerous, yet ventilation is of considerable use in 
the measles ; as is also a liequent change of linen, and cleanliness. 



PRACTICE OF PHYSIC. 217 

part of the disease, had attended those cases which he had 
observed. Several other writers have described the scar- 
let fever in the same manner, and I know physicians who 
have seen the disease in that form ; so that there can be no 
doubt of there being a scarlet fever not necessarily con- 
nected with an ulcerous sore throat, and therefore a dis- 
ease different from the Cynanche Maligna. 

652.] But, further, although in all the instances of scar- 
let fever which I have seen, (and in the course of forty 
years 1 have seen it six or seven times prevailing as an epf- 
demic in Scotland) the disease, in almost all the persons 
affected, was attended with an ulcerous sore throat, or was 
what Sauvages names the Scarlatina Anginosa; and al- 
though, in some instances the ulcers of the throat were of a 
putrid and gangrenous kind, and at the same time the dis- 
ease in all its symptoms resembled very exactly the Cy- 
nanche Maligna; yet I am still persuaded, that not only 
the Scarlatina of Sydenham, but that even the Scarlatina 
Anginosa of Sauvages, is a different disease from the Cy- 
nanche Maligna; and I have formed this opinion from the 
following considerations. 

653.] 1st, There is a scarlet fever entirely free from any 
affection of the throat, which sometimes prevails as an epi- 
demic; and therefore there is a specific contagion produc- 
ing a scarlet eruption without any determination to the 
throat. 

Idly, The Scarlatina, which, from its matter being ge- 
nerally determined to the throat, may be properly termed 
Anginosa, has, in many cases of the same epidemic, been 
without any affection of the throat ; and therefore the con- 
tagion may be supposed to be more especially determined 
to produce the eruption only. 

3d/y, Though in all the epidemics that I could alledg* 
to be those of the Scarlatina Anginosa, there have been 
some cases, which, in the nature of the ulcers, and in 
other circumstances, exactly resembled the cases of the 
Cynanche Maligna; yet I have as constantly remarked, 
that these cases have not been above one or two in a hun- 
dred, while the rest have all of them been with ulcers of a 
benign kind, and with circumstances hereafter to be des- 
cribed, somewhat different from those of the Cynanche 
Maligna. 

4/7//y, On the other hand, as I have two or three times 
seen the Cynanche Maligna epidemically prevailing ; so, 



218 PRACTICE OF PHYSIC. 

among the persons affected, I have seen instances of cases 
as mild as those of the Scarlatina Anginosa usually are : 
but here the proportion was reversed ; these mild cases 
were not one fifth of the whole, while the rest were of the 
putrid and malignant kind. 

Lastly, It applies to the same purpose to observe, that, 
of the Cynanehe Maligna, most of the instances terminate 
fatally ; while, on the other hand, that is the event of very 
few of the cases of the Scarlatina Anginosa. 

654.] From these considerations, though it may appear 
that there is some affinity between the Cynanehe Maligna 
and Scarlatina Anginosa, it will still remain probable that 
the two diseases are specifically different. I have been at 
some pains to establish this opinion : for, from all my ex- 
perience, I find, that those two diseases require a differ- 
ent treatment ; and I therefore now proceed to mention 
more particularly the circumstances of the Scarlatina An- 
ginosa. 

655.] This disease commonly appears about the begin- 
ning of winter, and continues throughout that season. It 
comes on with some cold shivering, and other symptoms 
of the fever which usually introduces the other exanthe- 
mata. But here there is no cough, nor the other catarrhal 
symptoms which attend the measles; nor is there that anx- 
iety and vomiting which commonly introduce the conflu- 
ent small-pox, and which more certainly introduce the 
Cynanehe Maligna. 

Early in the disease, some uneasiness is felt in the throat; 
and frequently the deglutition is difficult, generally more 
so than in the Cynanehe Maligna. Upon looking into the 
fauces, a redness and swelling appear in color and bulk ap- 
proaching to the state of these symptoms in the Cynanehe 
Tonsillaris ; but in the Scarlatina, there is always more or 
less of sloughs, which seldom appear in the Cynanehe Ton- 
sillaris ; and the sloughs are commonly whiter than those in 
the Cynanehe Maligna. 

While these appearances are discovered in the fauces, 
upon the third or fourth day a scarlet eruption appears on 
the skin in the same form as described in 314. This erup- 
tion is commonly more considerable and universal than in 
the Cynanehe ; but it seldom produces a remission of the 
fever. The eruption for the most part remains till the third 
or fourth day after its first appearance ; but then goes off, 
ending in a meally desquamation. At this time the fever 



PRACTICE OF PHYSIC. 219 

\isually subsides ; and generally, at the same time, some 
degree of sweat comes on. 

The sloughs on the fauces, which appeared early in the 
disease, continue for some days ; but then falling off, dis- 
cover the swelling abated, and an ulcer formed on one or 
both tonsils showing a laudable pus ; and soon after the fever 
has subsided, these ulcers heal up entirely. For the most 
part this disease has much less of coryza attending it 
than the Cynanche Maligna ; and, when there is a coryza 
attending the Scarlatina, the matter discharged is less acrid, 
and has not the fetid smell which it has in the other disease. 

In the Scarlatina, when the eruption has entirely disap- 
peared, it frequently happens, that in a few days after, 
the whole body is affected with an ahasarcous swelling ; 
which, however, in a few days more, gradually subsides. 

We have thus described the most common circumstances 
of the Scarlatina Anginosa ; and have only to add, that 
during the time of its being epidemic, and especially upon 
its first setting in, there are always a few cases in which the 
circumstances of the disease approach very nearly to those 
of the Cynanche Maligna ; and it is only in these instances 
that the disease is attended with any danger.* 

656.] With respect to the cure of this disease, when the 
symptoms of it are nearly the same with those of the Cy- 
nanche Maligna, it requires exactly the same treatment as 
directed in 317. 

657.] When the scarlet fever appears without any af- 
fection of the throat, the treatment of it is very simple, and 
is delivered by Dr. Sydenham. An antiphlogistic regimenf 
is commonly all that is requisite ; avoiding, on one hand, 
the application of cold air ; and, on the other, any increase 
of external heat. 

653.] In the ordinary state of the Scarlatina Anginosa, 
the same treatment is, in most cases, sufficient ; but as 
here, the fever is commonly more considerable, and there 
is likewise an affection of the throat, some remedies may be 
often necessary. 

659.] When there is a pretty high degree of fever, with 
a full pulse, and a considerable swelling of the tonsils, 

* These cases in which the disease is attended with danger, are, however, very few, and are 

only tin Teazing the patient by doing too much; tormenting him with a dote 

confinement to his bod, well furnished with blankets; and adding fuel to the flame, by forcing 

him to s\v:illow large quantities ot cordials and alcxipharmics. are the sure methods of increasing 

il the patient, distressed by the excessive ofhuousness of his sage doctor, is 

m the arms of Death, 

n must not however be carried too far, lest we induce a state of 
debility that way prove hurtful. 



■220 PRACTICE OF PHYSIC. 

bleeding is very proper, especially in adults ; and it has 
been frequently practised with advantage : but as, even in 
the Cynanche Tonsillaris, much bleeding is seldom neces- 
sary ; (305.) so, in the Scarlatina, when the state of the 
fever and the appearances of the fauces render the nature 
of the disease ambiguous, bleeding may be omitted ; and, 
if not altogether avoided, it should at least not be large, 
and ought not to be repeated. 

660.] Vomiting, and especially nauseating doses of eme- 
tics,* notwithstanding the inflamed state of the fauces, have 
been found very useful in this disease. An open belly is 
proper in every form of this disease ; and when the nau- 
seating doses of emetics operate a little downwards, they 
are more serviceable. 

661.] In every form of the Scarlatina Anginosa, through 
the whole course of it, detergent garglesf should be em- 
ployed, and more or less as the quantity of sloughs and the 
viscid mucus in the fauces may seem to require. 

662.] Even in the milder states of the Scarlatina Angi- 
nosa, it has been common with practitioners to exhibit the 
Peruvian bark through the whole course of the disease ; 
but we are assured, by much experience, that in such ca- 
ses it may be safely omitted, though in cases any ways am- 
biguous it may not be prudent to neglect this remedy. 

663.] The anasarcous swelling, which frequently follows 
the Scarlatina Anginosa, seldom requires any remedy; and, 
at least, the purgatives so much inculcated, and so com- 
monly exhibited, soon take oft' the anasarca. 



CHAPTER V. 

OF THE PLAGUE. 

SECTION I. 

Of the Phenomena of the Plague. 

664.] 'T^HE Plague is a disease which always arises 
JL from contagion ; which affects many persons 
about the same time ; proves fatal to great numbers, gene- 
rally produces fever ; and in most persons, is attended with 
buboes or carbuncles. 

* These have been mentioned in former notes. 

+ The detergent gargles were described in the note on article 317. Tincture of roses is gene- 
rally used, and in most cases answer every intention. If, however, the ulceration is considera- 
ble, and the sloughs do not easily cast off, resource must be bad to Dr. FothergiU's gargle, de»- 
cribed in article 317. 



PRACTICE OF PHYSIC. 221 

665.] These are the circumstances which, taken together, 
give the character of the disease ; but it is accompanied 
with many symptoms almost peculiar to itself, that, in dif- 
ferent persons, are greatly diversified in number and degree, 
and should be particularly studied. I would wish to lay 
a foundation for this ; but think it unfit for a person who 
has never seen the disease to attempt its particular history. 
For this, therefore, I must refer to the authors who have 
written on the subject ; but allowing those only to be con- 
sulted, who have themselves seen and treated the disease in 
all its different forms. 

666.] From the accounts of such authors, it appears to 
me, that the circumstances which particularly distinguish 
this disease, and especially the more violent and dangerous 
states of it, are 

1st, The great loss of strength in the animal functions, 
which often appears early in the disease. 

2dly, The stupor, giddiness, and consequent staggering, 
which resembles drunkenness, or the head-ach and various 
delirium ; which are all of them symptoms denoting a great 
disorder in the functions of the brain. 

Sdly, The anxiety, palpitation, syncope, and especially 
the weakness and irregularity of the pulse, which denotes 
a considerable disturbance in the action of the heart. 

4thly, The nausea and vomiting, particularly the vomit- 
ing or bile, which shows an accumulation of vitiated bile 
in the gall-bladder and biliary ducts, and from thence de- 
rived into the intestines and stomach ; all of which symp- 
toms I suppose to denote a considerable spasm, and loss of 
tone, in the extreme vessels on the surface of the body. 

5thly, The buboes or carbuncles, which denote an acri- 
mony prevailing in the fluids. And, 

Lastly, The Petechia?, hemorrhagies, and colliquative 
diarrhoea, which denote a putrescent tendency prevailing to 
a great degree in the mass of blood. 

667.] From the consideration of all these symptoms, it 
appears, that the plague is especially distinguished by a spe- 
cific contagion, often suddenly producing the most conside- 
rable symptoms of debility in the nervous system or mov- 
ing powers, as well as of a general putrescency in the fluids ; 
and it is from the consideration of these circumstances as 
the proximate cause, that I think both the prevention and 
cure of the plague must be directed. 

668.] If this disease should revisit the northern parts of 
2f 



222 PRACTICE OF PHYSIC. 

Europe, it is probable, that, at the time, there will be no 
physician then alive, who, at the first appearance of the 
disease, can be guided by his former experience, but must 
be instructed by his study of the writers on this subject, 
and by analogy. It is, therefore, I hope, allowable for me, 
upon the same grounds, to offer here my opinion with re- 
spect to both the prevention and cure of this disease. 

This paragraph was written before I had any notice of 
the plague of Moscow, anno 1771 ; but I think it will still 
apply to the case of Great Britain and of many other 
northern states. 



SECTION II. 

Of the Prevention of the Plague. 

669.] WITH respect to the prevention : As we are firm- 
ly persuaded that the disease never arises in the northern 
parts of Europe, but in consequence of its being imported 
from some other country ; so the first measure necessary, is 
the magistrate's taking care to prevent the importation : 
and this may generally be done by a due attention to bills 
of health, and to the proper performance of quarantines. 

670.] With respect to the latter, we are persuaded, that 
the quarantine of persons may safely be much Jess than 
forty days ; and, if this were allowed, the execution of the 
quarantine would be more exact and certain, as the tempta- 
tion to break it would be in a great measure removed. 

671. ] With respect to the quarantine of goods, it can- 
not be perfect, unless the suspected goods be unpacked and 
duly ventilated, as well as the other means employed for 
correcting the infection they may carry ; and, if all this 
were properly done, it is probable that the time commonly 
prescribed for the quarantine of goods might also be short- 
ened. 

672.] A second measure, in the way of prevention, be- 
comes requisite, when an infection has reached and prevail- 
ed in any place, to prevent that infection from spreading 
into other places. This can be done only by preventing 
the inhabitants, or the goods of any infected place, from 
going out of it, till they have undergone a proper quarantine. 

613.] The third measure for prevention, to be employed 
with great care, is to hinder the infection from spreading 



PRACTICE OF PHYSIC. 223 

among the inhabitants of the place in which it has arisen. 
The measures necessary for this, are to be directed by the 
doctrine laid down in 82 ; and from that doctrine we in- 
fer, that all persons who can avoid any near communica- 
tion with infected persons, or goods, may escape the in- 
fection. 

674.] For avoiding such communication, a great deal 
may be done by the magistrate : 1. By allowing as many 
of the inhabitants as are free from the infection, and not 
necessary to the service of the place, to go out of it. 2. By 
prohibiting all assemblies, or unnecessary intercourse of 
the people. 3. By taking care that necessary communica- 
tions be performed without contact. 4. By making such ar- 
rangements and provisions as may render it easy for the 
families remaining, to shut themselves up in their own 
houses. 5. By allowing persons to quit houses in which 
an infection appears, upon condition that they go into la- 
zarettoes. 6. I3y ventilating and purifying, or destroying 
at the public expence, all infected goods. Lastly, by 
avoiding hospitals, and providing separate apartments for 
infected persons. 

The execution of these measures will require great au- 
thority, and much vigilance and attention, on the part of 
the magistrate ; but it is not our province to enter into any 
detail on this subject of the public police. 

675.] The fourth and last part of the business of pre- 
vention, respects the conduct of persons necessarily remain- 
ing in infected places, especially of those obliged to have 
some communication with persons infected. 

676.] Of those obliged to remain in infected places, but 
not obliged to have any near communication with the sick, 
they may be preserved from the contagion by avoiding all 
near communication with other persons, or their goods ; 
and it is probable, that a small distance will answer the 
purpose, if, at the same time, there be no stream of air to 
carry the effluvia of persons, or goods, to some distance. 

677.] For those who are necessarily obliged to have a 
near communication with the sick, it is proper to let them 
know, that some of the most powerful contagions do not 
operate, but when the bodies of men exposed to the conta- 
gion are in certain circumstances which render them more 
liable to be affected by it ; and therefore, by avoiding these 
circumstances and causes, they may often escape infection. 

678.] The bodies of men are especially liable to be a/- 



224 PRACTICE OF PHYSIC. 

fected by contagions, when they are any ways considerably 
weakened by want of food, and even by a scanty diet, or 
one of little nourishment ; by intemperance in drinking 
which when the stupor of intoxication is over, leaves the 
body in a weakened state ; by excess in venery ; by great 
fatigue ; or by any considerable evacuation. 

679. The causes which, concurring with contagion, ren- 
der it more certainly active, are cold, fear, and full living. 

The several means, therefore, of avoiding or guarding 
against the action of cold (94, to 96.) are to be carefully 
studied. 

680.] Against fear the mind is to be fortified as well as 
possible, by inspiring a favorable idea of the power of pre- 
servative means ; by destroying the opinion of the incura- 
ble nature of the disease ; by occupying mens minds with 
business or labor ; and by avoiding all objects of fear, as 
funerals, passing bells, and any notice of the death of parti- 
cular friends. 

681.] A full diet of animal food increases the irritability 
of the body, and favors the operation of contagion ; and 
indigestion, whether from the quantity or quality of food, 
has the same effect. 

682. Besides giving attention to obviate the several cir- 
cumstances (609, 618, to 681.) which favor the operation 
of contagion, it is probable that some means may be em- 
ployed for strengthening the bodies of men, and thereby 
enabling them to resist contagion. 

For this purpose, it is probable, that the moderate use 
of wine, or of spirituous liquors, may have a good effect. 

It is probable also, that exercise, when it can be employ- 
ed, if so moderate as to be neither heating nor fatiguing to 
the body, may be employed with advantage. 

Persons who have tried cold bathing, and commonly feel 
invigorating effects from it, if they are any ways secure 
against having already received infection, may possibly be 
enabled to resist it by the use of the cold bath. 

It is probable, that some medicines also may be useful in 
enabling men to resist infection ; but amongst these I can 
hardly admit the numerous alexipharmics formerly propos- 
ed ; or, at least, very few of them, and those only of tonic 
power. Amongst these last we reckon the Peruvian bark ; 
and it is perhaps the most effectual. If any thing is to be 
expected from antiseptics, I think camphirc, whether in- 



PRACTICE OF PHYSIC. 225 

ternally or externally employed, is one of the most promis- 
ing. 

Every person is to be indulged in the use of any means 
of preservation of which he has conceived a good opinion, 
whether it be a charm or a medicine, if the latter be not di- 
rectly hurtful. 

Whether issues be useful in preserving from, or in mode- 
rating the effects of contagion, I cannot determine from the 
observations I have yet read. 

683.] As neither the atmosphere in general, nor any con- 
siderable portion of it, is tainted or impregnated with the 
matter of contagions ; so the lighting of fires over a great 
part of the infected city, or other general fumigations in 
the open air, are of no use for preventing the disease, and 
may perhaps be hurtful. 

684.] It would probably contribute much to check the 
progress of infection, if the poor were enjoined to make a 
frequent change of clothing, and were suitably provided 
for that purpose ; and if they were, at the same time, in- 
duced to make a frequent ventilation of their houses and 
furniture. 



SECTION III. 

Of the Cure of the Plague. 

685.] IN the cure of the plague, the indications are 
the same as those of fever in general, (126.) but here they 
are not all equally necessary and important. 

686.] The measures for moderating the violence of re- 
action, which operate by diminishing the action of the 
heart and arteries (128.) have seldom any place here, ex- 
cepting so far as the antiphlogistic regimen is generally 
proper. Some physicians, indeed, have recommended 
bleeding ; and there may occur cases in which bleeding may 
be useful; but, for the most part, it is unnecessary, and- 
in many cases it might be very hurtful. 

Purging has also been recommended ; and, in some de- 
gree, it may be useful in drawing off the bile, or other pu- 
trescent matters frequently present in the intestines; but a 
large evacuation this way may certainly be hurtful. 

687.] The moderating the violence of reaction, so far 
as it can be done by taking off the spasm of the extreme 



226 PRACTICE OF PHYSIC. 

vessels (151.) is a measure of the utmost necessity in the 
cure of the plague; and the whole of the means (152, to 
200.) suited to this indication are extremely proper. 

688.] The giving an emetic at the very first approach of 
the disease, would probably be of great service; and it is 
likely, that at some other periods of the disease, emetics 
might be useful, both by evacuating bile abundant in the 
alimentary canal, and by taking off the spasm of the ex- 
treme vessels. 

689.] From some principles with respect to fever in ge- 
neral, and with respect to the plague in particular, 1 am 
of opinion, that, after the exhibition of the first vomit, the 
body should be disposed to sweat; which ought to be rais- 
ed to a moderate degree only, but continued for at least 
twenty-four hours, or longer if the patient bear it easily. 

690.] This sweating should be excited and conducted 
agreeably to the rules laid down in 168. It is to be pro- 
moted b}' the plentiful use of diluents, rendered more 
grateful by vegetable acids, or more powerful by being 
impregnated with some portion of neutral salts. 

691.] To support the patient under the continuance of 
the sweat, a little weak broth, acidulated with juice of 
lemons, may be given frequently; and sometimes a little 
wine, if the heat of the body be not considerable. 

692.] If sudorific medicines are judged to be necessary, 
opiates are the most effectual and safe: but they should 
not be combined with aromatics; and probably may be 
more effectual, if joined with a portion of emetics, and of 
neutral salts. 

693.] If, notwithstanding the use of emetics and sudo- 
rifics, the disease should still continue, the cure must de- 
pend upon the employment of means for obviating debi- 
lity and putrescency ; and for this purpose, the various re- 
medies proposed above (from 201, to 227.) may all be ad- 
ministered, but especially the tonics; and of these the chief 
are cold drink and the Peruvian bark. 

694.] In the cure of the plague, some attention is due 
to the management of buboes and carbuncles: but we do 
not touch this, as it belongs to the province of surgery.* 

* The reader might possibly expert a detail of the medicines used in the plague, with their 
dn«>s and the manner of administering them ; but 1 thought it better to refer to the authors 
.Li?,, have either seen the disease, or who have expressly written on it. 

on consulting different authors, it appears, that every particular epidemic requires a different 
,„,,„', i n some parts of the cure at least. Should any young practitioner be unfortunate 
^ foiiJli u> have occasion to exercise his art in the care of the plague, he must chiefly be directed 
t>r the general indications of Lhe cure of fevers. 



PRACTICE OF PHYSIC. 227 



CHAPTER VI. 

OF ERYSIPELAS, OR ST. ANTHONY'S FIRE. 

695.] TN 274, I mentioned the distinction which I pro- 

A posed to make between the diseases to be named 

the Erythema and the Erysipelas ; and from thence it will 

appear, that Erysipelas, as an Erythema following fever, 

may have its place here. 

696.] I suppose the erysipelas to depend on a matter ge- 
nerated within the body, and which, analogous to the other 
cases of exanthemata, is, in consequence of fever, thrown 
out upon the surface of the body. I own it may be diffii- 
cult to apply this to every particular case of erysipelas : 
but I take the case in which it is generally supposed to ap- 
ply, that of the erysipelas of the face ; which I shall there* 
fore consider here. 

697.] The Erysipelas of the face comes on with a cold 
shivering, and other symptoms of pyrexia. The hot stage 
of this is frequently attended with a confusion of head, and 
some degree of delirium ; and almost always with drowsi- 
ness, or perhaps coma. The pulse is always frequent, 
and commonly full and hard. 

698.] When these symptoms have continued for one, 
two, or at most three days, there appears, on some part 
of the face, a redness, such as that described in (275.) as 
the appearance of Erythema. This redness, at first, is of 
no great extent ; but gradually spreads from the part it 
first occupied to the other parts of the face, commonly till 
it has affected the whole ; and frequently from the face it 
spreads over the hairy scalp, or descends on some part of 
the neck. As the redness spreads, it commonly disappears, 
or at least decreases, in the parts it had before occupied. 
All the parts upon which the redness appears are, at the 
same time, affected with some swelling, which continues 
for some time after the redness has abated. The whole 
face becomes considerably turgid ; and the eye-lids are 
often so much swelled as entirely to shut up the eyes. 

699.] When the redness and swelling have proceeded for 
some time, there commonly arise, sooner or later, blisters 
of a larger or smaller size, on several parts of the face. 
These contain a thill yellowish or almost colorless liquor, 



228 PRACTICE OF PHYSIC. 

which sooner or later runs out. The surface of the skin, 
in the blistered places, sometimes becomes livid and black- 
ish ; but this livor seldom goes deeper than the surface, or 
discovers any degree of gangrene affecting the skin. 'On 
the parts of the face not affected with blisters, the cuticle 
suffers, towards the end of the disease, a considerable des- 
quamation. Sometimes the tumor of the eye -lids ends in a 
suppuration. 

700.] The inflammation coming upon the face does not 
produce any remission of the fever which had before pre- 
vailed ; and sometimes the fever increases with the increas- 
ing and spreading inflammation. 

701.] The inflammation usually continues for eight or 
ten days ; and for the same time, the fever and symptoms 
attending it also continue. 

702.] In the progress of the inflammation the delirium 
and coma attending it sometimes go on increasing, and 
the patient dies apoplectic on the seventh, ninth, or ele- 
venth day of the disease. In such cases, it has been 
commonly supposed that the disease is translated from the 
external to the internal parts. But I have not seen any in- 
stance in which it did not appear to me, that the affection 
of the brain was merely a communication of the external 
affection, as this continued increasing at the same time 
with the internal. 

703.] When the fatal event does not take place, the in- 
flammation, after having affected a part, commonly the 
whole of the face, and perhaps the other external parts of 
the head, ceases. With the inflammation, the fever also 
ceases; and without any evident crisis, the patient returns; 
to his ordinary state of health. 

704.] This disease is not commonly contagious; but 
as it may arise from an acrid matter externally applied, 
50 it is possible that the disease may sometimes be commu- 
nicated from one person to another. 

Persons who have once labored under this disease are 
liable to returns of it. 

705.] The event of this disease may be foreseen from 
the state of the symptoms which denote more or less affec- 
tion of the brain. If neither delirium nor coma come on, 
the disease is seldom attended with any danger ; but when 
these symptoms appear early in the disease, and are in a 
considerable degree, the utmost danger is to be appre- 
hended. 



PRACTICE OF PHYSIC. 229 

70G.] As this disease often arises in the part, at the same 
time with the coming on of the pyrexia; as I have known 
it with all its symptoms, arise from an acrimony applied to 
the part; as it is commonly attended with a full and fre- 
quently a hard pulse; as the blood drawn in this disease 
shows the same crust upon its surface, that appears in the 
phlegmasia ; and, lastly as the swelling of the eye-lids, in 
this disease, frequently ends in a suppuration; so, from 
these considerations, it seems doubtful if this disease be 
properly, ia Nosology, separated from the Phlegmasia?. 
At any rate, I take the disease I have described to be what 
physicians have named the Erysipelas Phlegmonodes, and 
that it partakes a great deal of the nature of the Phleg- 
masia'. 

707.] Upon this conclusion, the Erysipelas of the face 
is to be cured very much in the same manner as phlegmo- 
nic inflammations, by blood-letting, cooling purgatives, 
and by employing every part of the antiphlogistic regi- 
men ;* and our experience has confirmed the fitness of this 
method of cure. 

708.] The evacuations of blood-letting and purging, 
are to be employed more or less according to the urgency 
of symptoms, particularly those of the pyrexia, and of 
those which mark an affection of the brain. As the pyrexia 
continues and often increases with the inflammation of the 
face ; so the evacuations mentioned may be employed at 
any time in the course of the disease. 

709.] In this, as in other diseases of the head, it is pro- 
per to put the patient, as often as he can easily bear it, into 
somewhat of an erect posture. 

710.] As in this disease there is always an external af- 
fection, and as in many instances there is no other; so va- 
rious external applications to the part affected have been 
proposed ; but almost all of them are of doubtful effect. 
The narcotic, f refrigerant, and astvingent| applications, 
are suspected of disposing to gangrene ; spirituous|| appli- 
cations seem to increase the inflammation ; and all oily or 
Avatery§ applications seem to occasion its spreading. The 
application that seems most safe, and which is now most 

* The antiphlogistic regimen, &c. have been described in former notes. See article 129, ct seq. 
fThe leavMot solatium, oi hemlock, or henbane, and other similar plains applied as fo- 
mentations, 
t Solution* of Saccharum Saturni, or Vitriolum album, applied cold. 

.illy it they arc such a.-, are compounded with aromatics or volatile salts, as campho- 
rated spirit of wine, Hun-;. 

woo ii evident, because they eonfi :nous liquor discharged from the part 

aSected. 

2 G 



230 PRACTICE OF PHYSIC. 

commonly employed, is that of a dry mealy powder fre- 
quently sprinkled upon the inflamed parts * 

711.] An Erysipelas Phlegmonodes frequently appears 
on other parts of the body, beside the face ; and such 
other erysipelatous inflammations frequently end in sup- 
puration. These cases are seldom dangerous. At com- 
ing on, they are sometimes attended with drowsiness, and 
even with some delirium ; but this rarely happens ; and 
these symptoms do not continue after the inflammation is 
formed. I have never seen an instance of the translation 
Of this inflammation from the limbs to an internal part ; 
and though these inflammations of the limbs be attended 
with pyrexia, they seldom require the same evacuations 
as the erysipelas of the face. At first they are to be treat- 
ed by dry mealy applications only ; and all humid appli- 
cations, as fomentations, or poultices, are not to be ap- 
plied, till, by the continuance of the disease, by the in- 
crease of swelling, or by a throbbing felt in the part, it 
appears that the disease is proceeding to suppuration. 

112.] We have hitherto considered erysipelas as in a 
great measure of a phlegmonic nature ; and agreeably to 
that opinion, we have proposed our method of cure. But 
it is probable, that an erysipelas is sometimes attended 
with, or is a symptom of, a putrid fever; and, in such 
cases, the evacuations proposed above may be improper, 
and the use of the Peruvian bark may be necessary ; but I 
cannot be explicit upon this subject, as such putrid case* 
have not come under my observation. 



CHAPTER VII. 

OF THE MILIARY FEVER. 

713.] nr^HIS disease is said to have been unknown to 

X the ancients, and that it appeared, for the 

first time, in Saxony, about the middle of the last cen- 

tury.f It is said to have spread from thence into all the 

* Wheat flour is apt to run into hard lumps by the thin acrimonious liquor which always ex- 
hales from parts affected with erysipelas. Oatmeal not being so liable to this inconvenience; is 
therefore preferable : it ought to be wiped oft, and a fresh quantity applied twice or thrice a 

.Many practitioners reaommend the application of cabbage leaves to erysipelatous swellings, 
and their efficacy has been frequently approved. They ought to be removed as soon as they grow 
warm or uneasy, and fresh cold ones applied. 

+ Hoffman, Welsch, and several other writers, fix the first appearance or this disease at Leip- 
tic ia the years ltol and Jba2. This opinion, however, is false j for descriptions of miliary erup- 



PRACTICE OF PHYSIC. 234 

other parts of Europe ;* and, since the period mentioned, 
to have appeared in many countries in which it had never 
appeared before. 

714.] From the time of its having been first particularly 
observed, it lias been described and treated of by many 
different writers ; and by all of them, till very lately, has 
been considered as a peculiar idiopathic disease. 

It is said to have been constantly attended with peculiar 
symptoms. It comes on with a cold stage, which is often 
considerable. The hot stage which succeeds, is attended 
with great anxiety, and frequent sighing. The heat of 
the body becomes great, and soon produces profuse sweat- 
ing ; preceded, however, by a sense of pricking, as of 
pin-points in the skin; and the sweat is of a peculiarly 
rank and disagreeable odor. The eruption appears sooner or 
later in different persons, but at no determined period of 
the disease. It seldom or never appears on the face ; but 
discovers itself first upon the neck and breast, and from 
thence often spreads over the whole body. 

715.] The eruption named Miliary is said to be of two 
kinds, the one named the Red, the other the White Milia- 
ry. The former which in English is strictly named the 
liash, is commonly allowed to be a symptomatic affection ; 
and as the latter is the only one that has any pretensions to 
be considered, as an idiopathic disease, it is this alone that 
I shall more particularly describe and treat of in the pre- 
sent chapter. 

716.] What then is called the White Miliary eruption ap- 
pears at first like the red, in very small red pimples, for the 
most part distinct, but sometimes clustered together. Their 
slight prominence is distinguished better by the finger than 
by the eye. Soon after the appearance of this eruption, 
and at least on the second day, a small vesicle appears upon 

tions arc to be found in the writings of the ancients, and among the moderns we find Riverius 
describing it in France, just after the appearance of the comet of the year 1018 ; to which phe- 
nomenon that author ascribes the fatal epidemic, as well as the bloody wars that were at tluit 
turn: making horrid devastations in Europe. 

* We meet with several accounts of the appearance of the miliary eruption in different parts 
of Europe sooh after the middle of the last century, not only by medical writers, but by gene- 
ral historians ; among the latter of whom we may mention Robert Sibbald, who takes notice of 
it in his Scotia lllustrata, published at Edinburgh in the year 1684. (Sibbald, however, was a 
physician.) To enumerate the medical writers who have described the disease in the different 
pans of Europe, would take more room than the short compass ot these notes admits, the chief 
of them arc V\ each, Hoffman, Langius, lleyijer, Bonetus, Gnnwald, Sydenham, Kamizina, Fuch- 
sius, \ 

The authors above mentioned, and several others about the end of the last and beginning of 
this century, entertained various opinions concerning the nature of the miliary eruption, some of 
them supposing it to be a critical termination of a peculiar fever, and others on the contrary 
Strenuously insisting that it WJ^ only accidental or symptomatic, and never critical or salutary. 
, which was can icd ou with some warmth, is now terminated, as will appear by 
>>\vs; DUt the inquisitive young physician will find both entertainment and instruction 
•ii perusing it. A very govd abstract ot it occurs in Dc Haenl treatise oh the division ot Feven,. 



232 PRACTICE OF PHYSIC. 

the top of each pimple. At first the vesicle is whey co- 
lored ; but soon becomes white, and stands out like a 
globule on the top of the pimple. In two or three days 
these globules break, or are rubbed off ; and are succeeded 
by small crusts, which soon after fall off in small scales. 
While one set of pimples takes this course, another set suc- 
ceeds ; so that the disease often continues upon the skin for 
many days together. Sometimes when one crop of this 
eruption has disappeared, another, after some interval is 
produced. And it has been further observed, that in some 
persons there is such a tendency to this disease, that they 
have been affected with it several times in the course of 
their lives. 

717.] This disease is said to affect both sexes, and per- 
sons of all ages and constitutions ; but it has been observed, 
at all times, to affect especially, and most frequently, ly- 
ing-in women. 

718.] This disease is often accompanied with violent 
symptoms, and has frequently proved fatal. The symp- 
toms attending it are, however, very various. They are, 
in one or other instances, all the several symptoms attend- 
ing febrile diseases ; but I cannot find that any symptom or 
course of symptoms are steadily the same in different per- 
sons, so as to furnish any specific character to the disease. 
When the disease is violent, the most common symptoms 
are phrenitic, comatose, and convulsive affections which are 
also symptoms of all fevers treated by a very warm regimen. 

719.] While there is such a variety of symptoms appear- 
ing in this disease, it is not to be expected that any one 
particular method of cure can be proposed : and accord- 
ingly we find, in different writers, different methods and 
remedies prescribed ; frequent disputes about the most 
proper ; and those received and practised by some, oppos- 
ed and rejected by others. 

720.] I have thus given an account of what I have found 
delivered by authors who have considered the white miliary 
fever as an odiopathic disease : but, now, after having 
often observed the disease, I must say that I doubt much if 
it ever be such an idiopathic, as has been supposed, and I 
suspect that there is much fallacy in what has been written 
on the subject. 

721.] It seems to me very improbable, that this should 
have been really a new disease when it was first considered 
as such. There appear to me very clear traces of it in au- 



PRACTICE OF PHYSIC. 233 

tliors who wrote long before that period ; and, though 
there were not, we know that the descriptions of the an- 
cients were inaccurate and imperfect, particularly with res- 
pect to cutaneous affections ; whilst we know also very- 
well, that those affections which usually appeared as S} 7 mp- 
tomatic only, were commonly neglected, or confounded 
together under a general appellation. 

722;] The antecedent symptoms of anxiety, sighing, 
and pricking of the skin, which have been spoken of as pe- 
culiar to this disease, are, however, common to many 
others ; and, perhaps to all those in which sweatings are 
forced out by a warm regimen. 

Of the symptoms said" to be concomitant of this eruption, 
there are none which can be said to be constant and peculiar 
but that of sweating. This, indeed, always precedes and ac- 
companies the eruption ; and, while the mliary eruption at- 
tends many different diseases, it never, however, appears in 
any of these, but after sweating ; and, in persons laboring un- 
der these diseases, it does not appear, if sweating be avoid- 
ed. It is therefore probable, that the eruption is the effect 
of sweating ; and that it is the produce of a matter, not 
before prevailing in the mass of blood, but generated, un- 
der particular circumstances, in the skin itself. That it de- 
pends upon particular circumstances of the skin, appears 
further from hence, that the eruption seldom or never ap- 
pears upon the face, although it affects the whole of the bo- 
dy besides ; that it comes upon those places especially 
which are more closely covered ; and that it can be brought 
out upon particular parts by external applications. 

723. J It is to be observed, that this eruptive disease dif- 
fers from the other exanthemata in many circumstances ; in 
its not being contagious, and therefore never epidemic ; 
that the eruption appears at no determined period of the 
disease ; that the eruption has no determined duration ; 
that successive eruptions frequently appear in the course of 
the same fever ; and that such eruptions frequently recur 
In the course of the same person's life. 

t All these circumstances render it extremely probable, 
that, in the miliary fever, the morbific matter is not a sub- 
sisting contagion communicated to the blood, and thence, 
in consequence of fever and assimilation, thrown out upon 
the surface of the body ; but a matter occasionally produc- 
ed in the skin itself, by sweating. 

724.] This conclusion is further rendered probable, from 



23* PRACTICE OF' PHYSIC. 

hence, that, while the miliary eruption has no peculiar 
symptoms, or concourse of symptoms, belonging to it ; 
yet upon occasion, it accompanies almost all febrile dis- 
eases, whether inflammatory or putrid, if these happen to 
be attended with sweating ; and from thence it may be 
presumed, that the miliary eruption is a symptomatic affec- 
tion only, produced in the manner we have said. 

725.] But, as this symptomatic affection does not always 
accompany every instance of sweating, it may be proper 
to inquire what are the circumstances which especially de- 
termine this eruption to appear ? To this, however, I can 
give no full and proper answer. I cannot say that there is 
any one circumstance which in all cases gives occasion to this 
eruption ; nor can I say what different causes may, in dif- 
ferent cases, give occasion to it. • There is only one obser- 
vation I can offer to the purpose of this inquiry ; and it is, 
that, of the persons, sweating under febrile diseases, those 
are especially liable to the miliary eruption, who have been 
previously weakened by large evacuations, particularly of 
blood. This will explain why it happens to lying-in wo- 
men more frequently than to any other persons ; and to 
confirm this explanation, I have remarked, that the erup- 
tion happened to women not in child -bed, but who had been 
much subjected to a frequent and copious menstruation ; 
and to an almost constant fluor albus. I have also had 
occasion to observe it happen to men in fevers, after wounds 
from which they had suffered a great loss of blood. 

Further, that this eruption is produced by a certain 
state of debility, will appear probable, from its often oc- 
curring in fevers of the putrid kind, which are always at- 
tended with great debility. It is true, that it also some- 
times attends inflammatory diseases, when it cannot be ac- 
counted for in the same manner ; but I believe it will be 
found to attend especially those inflammatory diseases in 
which the sweats have been long protracted or frequently 
repeated, and which have thereby produced a debility, 
and perhaps a debilitating putrid diathesis. 

726.] It appears so clearly to me, that this eruption is 
always a symptomatic* and factitious affection, that I am 

* As this disease is always symptomatic and never idiopathic, the method of curing must ne- 
cessarily vary in diffeient cases ; the chief attention of the physician must therefore be turned 
to the primary disease, and to the means of preventing this symptom from appearing in those 
diseases which it accompanies. 

The author judiciously begins his method of cure by giving directions for preventing tne erup- 
tion, which he properly supposes to be entirely factitious, and to depend on the application »t 
too much heat. With a proper attention to the direction, given in the text, we may i 
prevent the eruption. If, however, the eruption is present before the physician u called, UMJK 
remedies inu9t be used for its removal that are eumerated in the subsequent articles. 



PRACTICE OF PHYSIC. 2 35 

persuaded it may be in most cases prevented merely by 
avoiding sweats. Spontaneous sweatings, in the begin- 
ning of diseases, are very rarely critical; all sweatings, not 
evidently critical, should be prevented ; and the promot- 
ing them, by increasing external beat, is commonly very 
pernicious. Even critical sweats should hardly be encou- 
raged by such means. If therefore, spontaneous sweats 
arise, they are to be checked by the coolness of the cham- 
ber ; by the lightness and coolness of the bed-clothes ; by 
the person's laying out their hands and arms, and by their 
taking cold drink: and, by these precautions, I think I 
have frequently prevented miliary eruptions, which were 
otherwise likely to have appeared, particularly in lyino-.in 
"women. 

727.] But it may happen, when these precautions have 
been neglected, or from other circumstances, that a mi- 
liary eruption does actually appear ; and the question will 
then be put, how the case is to be treated ? It is a question 
of consequence, because I believe that the matter here ve- 
nerated is often of a virulent kind ; it is frequently the off- 
spring of putrescency ; and, when treated by increasing 
the external heat of the body, it seems to acquire a virut 
lence which produces those symptoms mentioned in 718, 
and proves certainly fatal. 

It has been an unhappy opinion with most physicians, 
that eruptive diseases were ready to be hurt by cold; and 
that it was therefore necessary to cover up the body very 
closely, so as thereby to increase the external heat. We 
now know that this is a mistaken opinion ; that increasing 
the external heat of the body is very generally mischiev- 
ous ; and that several eruptions not only admit,' but require 
the application of cold air. We are now* persuaded, that 
the practice which formerly prevailed, in the case of milia- 
ry eruptions, of covering up the body close, and both by 
external means, and internal remedies, encouraging the 
sweatings which accompany this eruption, was highly per- 

* The present rational practice lias entirely altered the regimen in fevers; and instead or 
macerating the patient in a hot bed, and obliging him to breathe the corrupt air of a confined 
chamber, we now cover him with light bed-clothes, and ventilate hurooin. 

li may, however, be necessary toguard the young physician against the excess of this practice. 
me precept. Omttc mmitim meet, should alwavs be attended to. If the patient feels any dis- 
il if he should suffer rigors, or trembles trom the admission of cold air, it is 
certainly prejudicial, and its admission ought to be regulated. 

It may not be improper to mention another caution, viz. That the voung practitioner must 
not, b) the means here recommended, check sweats that are really critical. To determine 
what sweats are, and what are not, critical, is perhaps in some cases,' attended with considers, 
hie difficulty. In general, however, critical sweats may be known by their happening on the 
critical days before mentioned in article 107. et seq. and by their always being immediately fal- 
lowed by an abatement of all, or at least the greatest part, of the symptoms. 



236 PRACTICE OF PHYSIC. 

nicious, and commonly fatal. I am therefore of opinion, 
even when a nvliary eruption has appeared, that in all ca- 
ses where the sweating is not manifestly critical, we should 
employ all the several means of stopping it that are men- 
tioned above; and I have sometimes had occasion to observe, 
that even the admission of cool air was safe and useful. 

728. J This is, in general, the treatment of miliary erup- 
tions; but, at the same time, the remedies suited to Hie 
primary disease, are to be employed ; and therefore, when 
the eruption happens to accompany inflammatory affec- 
tions, and when the fulness and hardness of the pulse or 
other symptoms show an inflammatory state present, the 
case is to be treated by blood-letting, purging, and other 
antiphlogistic remedies. 

Upon the other hand, when the miliary eruption attends 
diseases in which debility and putrescency prevail, it will 
be proper to avoid all evacuations, and employ tonic and 
antiseptic remedies, particularly the Peruvian bark, cold 
drink, and cold air. 

I shall conclude this subject with mentioning, that the 
venerable octogenarian practitioner, de Fischer, when 
treating of this subject, in laving down the indications of 
cure, has given this as one of them : " Excretionis peri- 
pherics nop primariam habere rationem." 



CHAPTER VIII. 

OF THE REMAINING EXANTHEMATA. 

URTICARIA, PEMPHIGUS, AND APHTHA. 

729.] r T"HIE Nettle Rash is a name applied to two dif- 
X ferent diseases. The one is the chronic erup- 
tion described by Dr. Heberden in the Medical Transac- 
tions, Vol. I. art. xvii. which, as not being a febrile dis- 
order, does not belong to this place. The other is the 
Urticaria of our Synopsis, which as taken into every 
system of Nosology as one of the Exanthemata Febrilia, 
is properly to be treated of here. 

730.] I have never observed this disease as contagious 
and epidemic; and the few sporadic cases of it which have 
occured to me, have seldom taken the regular course des- 
cribed by authors. At the same time, as the accounts of 



PRACTICE OF PHYSIC. 237 

(Liferent authors are not very uniform, and hardly consist- 
ent, I cannot enter further into the consideration of this 
subject : and I hope it is not very necessary, as on all hands 
u \a agreed to be a mild disease, and such as seldom re- 
quires the use of remedies. It is generally sufficient to ob- 
serve an antiphlogistic regimen, and to keep the patient in 
a temperature that is neither hot nor cold. 

731.] The Pemphigus, or Visicular fever, is a rare and 
uncommon disease, and very few instances of it are record- 
ed in the writings of physicians. As I have never had oc- 
casion to see it, it would be improper for me to treat of it ;* 
and I do not choose to repeat after others, while the disease 
has yet been little observed, and its character does not seem 
to be exactly ascertained. Vid. Acta Helvetica, vol. ii. 
p. 260. Synops. Nosolog. vol. ii. p. 149. 

732.] The Aptha, or Thrush, is a disease better known; 
and, as it commonly appears in infants, it is so well under- 
stood, as not to need our treating of it here. As an idiopa- 
thic disease, affecting adults, I have not seen it in this coun- 
try: but it seems to be more frequent in Holland ; and, 
therefore, for the study of it, I refer to Dr. Boerhaave, 
and his commentator Van Swieten, whose works are in 
every body's hands. f 

733.] The Petechia has been, by all our Nosologists, 
enumerated amongst the exanthemata ; but as, according 
to the opinion of most physicians, it is very justly held to 
be always a symptomatic affection only, I cannot give it a 
place here. ' 

* It appears from the following passage in llie author* Synopsis, that lie had afterwards seen 

:t : " Collega noster exiinus Franctscus Heme, mihi homtnem leviter febiicitantem ostendit, 

" cui, piimum in brachiis, et successive demum in totocorpore, visieukemagnitudine avellanae 

i sunt, et post duos tresvedies e flu so humoris serosi pauxillo, cohapss sunt. Haeo 

tiutem Dullam indolem vel lypum peculiarem monstrabat, et cito disparuit nequaquam, 

" contagiosa." 

+ Boerhaave only saw aphthae twice without] and preceding, fever, and Van Swieten only 
once; but Ketelaer sau he has frequently seen them. Tbey sometimes actompanJTtnflamm a- 
tmns ol the viscera, and other inflammatory fevers, and are often difficult to remove. They 
are to be treated in the same manner as the ulcerations in the Cynanche maligna, by gargles of 
the deiersive kind, until the aphthous crust sepaiates and ta.ls off; but when that crust has fal- 
len oil, the painfulnesa of the nakedly exposed sensible parts requires emollient applications; 
of which kind a decoction of Rad. Al'th or an infusion of linseed, are proper gargles alone : if 
honey be added, the palicnt complains of iis making the parts smart. The pauent's diet ought 
lo be of the mildest kind, that it may he swallowed without causing much pain. 

The aphthous crust frequently appears at the anus, which symptom generally leads us to con- 
iluue, as Is really the case, that aphtha? covers the whole intestinal canal. Hence considerable 
danger arises. The absorbent I, and refuse admittance to all nourishment; hence 

an increased debility, with all its evil consequences, In these cases, a nutritive, liquid, and 
detersive diet, must be used. For this purpose a decoction ef bread, with wine and honey, is 
the properest dunk. Such a decoction' is extremely nutritive, and also averse to p'a'.: 
and therefore well adapted to the exigency of the case. 



"3H 



238 PRACTICE OF PHYSIC. 

BOOK IV. 

OF HEMORRHAGIES. 



CHAPTER I. 
OF HEMORRHAGY IN GENERAL. 

734.] TN establishing a class or order of diseases under 
J. the title of Hemorrhagies, Nosologists have 
employed the single circumstance of an effusion of red 
blood, as the character of such a class or order. By this 
means they have associated diseases which in their nature 
are very different ; but, in every methodical distribution, 
such arbitrary and unnatural associations should be avoid- 
ed as much as possible. Further, by that management 
Nosologists have suppressed or lost sight of an established 
and well-founded distinction of hemorrhagies into Active 
and Passive. 

735.] It is my design to restore this distinction ; and I 
shall therefore here, under the title of Hemorrhagies, com- 
prehend those only which have been commonly called Ac- 
tive, that is, those attended with some degree of pyrexia ; 
which seem always to depend upon an increased impetus 
of the blood in the vessels pouring it out, and which chiefly 
arise from an internal cause. In this I follow Dr. Hoffman, 
who joins the active hemorrhagies with the febrile diseases ; 
and have accordingly established these hemorrhagies as an 
order in the class of pyrexia. From this order I exclude 
all those effusions of red blood that are owing entirely to 
external violence ; and all those which, though arising 
from internal causes, are, however, not attended with py- 
rexia, and which seem to be owing to a putrid fluidity of 
the blood, to the weakness or to the erosion of the vessels, 
rather than to any increased impetus of the blood in them. 

736.] Before proceeding to treat of those proper he- 
morrhagies which form an order in our Nosology, I shall 
treat of active hemorrhagy in general ; and indeed the se- 
veral genera and species, to be treated of particularly af- 



PRACTICE OF PHYSIC. 239 

terwards, have so many circumstances in common with one 
another, that the general consideration to be now offered 
wiii prove both proper and useful. 



SECTION I. 

Of the Phenomena of Hemorrhage/. 

*737.] The phenomena of hemorrhagy are generally the 
following. 

Hemorrhagies happen especially in plethoric habits, and 
to persons of a sanguine temperament. They appear most 
commonly in the spring, or in the beginning of summer. 

For some time, longer or shorter in different cases, be- 
fore the blood flows, there are some symptoms of fulness 
and tension about the parts from whence the blood is to 
issue. In such parts as fall under our view, there are some 
redness, swelling, and sense of heat or of itching ; and in 
the internal parts from which blood is to flow, there is a 
sense of weight and heat ; and, in both cases, various 
pains are often felt in the neighboring parts. 

738.] When these symptoms have subsisted for some 
time, some degree of a cold stage of pyrexia comes on, 
and a hot stage is formed ; during which, the blood flows 
of a florid color, in a greater or lesser quantity, and conti- 
nues to flow for a longer or shorter time ; but commonly, 
after some time, the effusion spontaneously ceases, and to- 
gether with it the pyrexia also. 

739.] During the hot stage which precedes an hemor- 
rhagy, the pulse is frequent, quick,* full, and often hard ; 
but as the blood flows, the pulse becomes softer and less 
frequent. 

740.] In hemorrhagies, blood drawn from a vein, does, 
upon its concreting, commonly shoAv the gluten separated, 
or a crust formed, as in the cases of Phlegmasia. 

741.] Hemorrhagies from internal causes, having once 
happened, are apt, after a certain interval, to return ; in 
some cases very often, and frequently at stated periods. 

742.] These are, in general, the phenomena ,of hemor- 
rhagy ; and if in somecases, all of them be not exquisitely 
marked, or if perhaps some of them do not at all appear, 

• The difference between a frequent and gaick puke, was mentioned in a note on aniqlc 3&». 



240 PRACTICE OF PHYSIC. 

it imports only, that, in different cases the system is more 
or less generally affected ; and that, in some cases, there 
are purely topical hemorrhagies, as there are purely topi- 
cal inflammations. 



SECTION II. 

Of the Proximate Cause of Hemorrhagy. 

743.] THE pathology of hemorrhagy seems to be sufli- 
ciently obvious. Some inequality in the distribution of 
the blood occasions a congestion in particular parts of the 
sanguiferous system; that is, a greater quantity of blood 
is poured into certain vessels than their natural capacity is 
suited to receive. These vessels become thereby prctcrna- 
turally distended ; and this distention, proving a stimulus 
to them, excites their action to a greater degree than 
usual, which, pushing the blood with unusual force into 
the extremities of these vessels opens them by anastomosis, 
or rupture; and, if these extremities be loosely situated on 
external surfaces, or on the internal surfaces of certain ca- 
vities that open outwardly, a quantity of blood flows out 
of the body. 

744.] This reasoning will, in some measure, explain the 
production of hemorrhagy. But it appears to me, that, in 
most cases, there are some other circumstances that concur 
to produce it: for it is probable, that, in consequence of con- 
gestion, a sense of resistance arises, and excites the action 
of the Vis Medicatrix Naturae, the exertions of which are 
usually made by the formations of a cold stage of pyrexia, 
inducing" a more vigorous action of the vessels ; and the 
concurrence of this exertion more effectually opens the 
extremities, and occasions the flowing out of the blood. 

745.] What has been delivered in the two preceding 
paragraphs, seems to explain the whole phenomena of he- 
morrhagy, except the circumstance of its frequent recur- 
rence, which I apprehend may be explained in the follow- 
ing manner. The congestion and consequent irritation 
being taken off by the flowing of the blood; this therefore, 
soon after, spontaneously ceases ; but, at the same time, 
the internal causes which had before produced the unequal 
distribution of the blood, commonly remain, and must 
now operate the more readily, as the over-stretched and 



PRACTICE OF PHYSIC. 241 

relaxed vessels of the part will more easily admit of a con- 
gestion of blood in them, and, consequently, produce the 
.same series of phenomena as before. 

746.] This may sufficiently explain the ordinary return 
of hemorrhagy ; but there is still another circumstance, 
which, as commonly concurring, is to be taken notice of ; 
and that is, the general plethoric state of the system, 
which renders every cause of unequal distribution of more 
considerable effect. Though hemorrhagy may often de- 
pend upon the state of the vessels of a particular part be- 
ing favorable to a congestion's being formed in them ; yet, 
in order to that state's producing its effect, it is necessary 
that the whole system should be at least in its natural ple- 
thoric condition ; and, if this should be in any degree in- 
creased beyond what is natural, it will still more certainly 
determine the effects of topical conformation to take place. 
The return of hemorrhagy, therefore, Avill be more cer- 
tainly occasioned, if the system becomes preternaturally 
plethoric ; but hemorrhagy has always a tendency to in- 
crease the plethoric state of the system, and, consequent- 
ly, to occasion its own return. 

747.] To show that hemorrhagy does contribute to pro- 
duce or increase the plethoric state of the system, it is on- 
ly necessary to observe, that the quantity of serous fluids 
being given, the state of the excretions depends upon a 
certain balance between the force of the larger arteries pro- 
pelling the blood, and the resistance of the excretories: 
but the force of the arteries depends upon their fulness and 
distension, chiefly given to them by the quantity of red 
globules and gluten, which are for the greatest part con- 
fined to the red arteries; and therefore, the spoliation made 
by an hemorrhagy, being chiefly of red globules and glu- 
ten, the effusion of blood must leave the red arteries 
more empty and weak. In consequence of the weaker ac- 
tion of the red arteries, the excretions are in proportion di- 
minished ; and, therefore, the ingesta continuing the 
wine, more fluids will be accumulated in the larger ves- 
It is by this means that the loss of blood by hem or- 
rhagies, whether artificial or spontaneous, if within certain 
bounds, is commonly so soon recovered : but as the dimi- 
nution of the excretions, from a less quantity of fluid be- 
ing impelled into the excretories, gives occasion to these 
Is to fall into a contracted state ; so, if this shall con- 
tinue Ion' els will become more rigid, and will 



243 PRACTICE OF PHYSIC- 

not yield to the same impelling force as before. Although 
the arteries, therefore, by new blood collected in them, 
shall have recovered their former fulness, tension, and 
force ; yet this force will not be in balance with the resist- 
ance of the more rigid excretories, so as to restore the for- 
mer state of excretion ; and, consequently, a further ac- 
cumulation will take place in the arteries, and an increase 
of their plethoric state be thereby induced. In this man- 
ner, we perceive more clearly, that hemorrhagy, as pro- 
ducing a more plethoric state of the system, hasatenaen- 
cy to occasion its own recurrence with greater violence ; 
and, as the renewal and further accumulation of blood re- 
quire a determinate time, so, in the several repetitions of 
hemorrhagy, that time will be nearly the same ; and there- 
fore the returns of hemorrhagy will be commonly at stated 
periods, as has been observed frequently to happen. 

748.] I have thus explained the nature of hemorrhagy 
in general, as depending upon some inequality in the dis- 
tribution of the blood, occasioning a congestion of it in par- 
ticular parts of the sanguiferous system. It is indeed pro- 
bable, that, in most persons, the several parts of the san- 
guiferous system, are in balance with one another ; and 
that the density, and consequently the resistance, in the 
several vessels, is in proportion to the quantity of blood 
which each should receive ; from whence it frequently 
happens, that no inequality in the distribution of the blood 
takes place in the course of a long life. If, however, we con- 
sider that the sanguiferous system is constantly in a pletho- 
ric state, that is, that the vessels are constantly distended 
beyond that size which they would be of, if free from any 
distending force, we shall be satisfied that this s^ate may be 
readily changed. For as, on the one hand, the vessels are 
elastic, so as to be under a constant tendency to contract 
upon the withdrawing of any part of the distending force ; 
and, on the other hand, are not so rigid but that, by an in- 
crease of the impetus of the blood in them, they may be 
more than ordinarily distended ; so we can easily under- 
stand how, in most persons, causes of an increased contrac- 
tion or distension may arise in one part or other of the 
system, or that an unequal distribution may take place; 
and how, in an exquisitely distended or plethoric system, 
a small inequality in the distribution of the blood may 
form those congestions which give occasion to hemorrhagy. 

749.] In this manner I endeavor to explain how hemor- 



PRACTICE OF PHYSIC. 243 

rhagy may be occasioned atany period of life, or in any 
part of the body: but hemorrhagies happen in certain parts 
more frequently that in others, and at certain periods of 
life more readily than at others ; and therefore in deliver- 
ing the general doctrine of hemorrhagy, it may be required 
that I should explain those circumstances which produce 
the specialities mentioned ; and I shall now attempt it. 

150.] The human body, from being of a small bulk at 
its first formation, grows afterwards to a considerable size. 
This increase of bulk consists, in a great measure, in the 
increase of the quantity of fluids and a proportional en- 
largement of the containing vessels. But at the same time, 
the quantity of solid matter is also gradually increased ; 
and, in whatever manner we may suppose this to be done, 
it is probable that the progress, in the whole growth of 
animal bodies, depends upon the extension of the arterial 
system ; and such is the constitution of the sanguiferous 
iystem, that the motion of the blood in the arteries has a 
constant tendency to extend them in every dimension. 

151.] As the state of the animal solid is, at the first for- 
mation of the body, very lax and yielding ; so the extension 
of the system proceeds, at first, very fast: but, as the ex- 
tension gives occasion to the apposition of more matter to 
the solid parts, these are, in proportion to their extension, 
constantly acquiring a greater density, and therefore giving 
more resistance to their further extension and growth. Ac- 
cordingly, we observe, that as the growth of the body ad- 
vances, its increase, in any given time, becomes propor- 
tionally less and less, till at length it ceases altogether. 

752.] This is the general idea of the growth of the hu- 
man body, till it attain the utmost bulk which it is capable 
of acquiring : but it is to be remarked, that this growth 
does not proceed equally in every part of the body, it be- 
ing requisite for the economy of the system, that certain 
parts should be first evolved, and should also acquire their 
full bulk sooner than others. This appears particularly 
with respect to the head, the parts of which appear to be 
first evolved, and soonest to acquire their full size. 

753.] To favor this unequal growth, it is presumed, that 
the dimensions or the laxity of the vessels of the head, or 
that the direction of the force of the blood, are adapted to 
the purpose ; and from what has been said in 751, it will 
also certainly follow, that as the vessels of the head grow 
fastest, and soonest acquire their full size, so they will 



244 PRACTICE OF PHYSIC. 

soonest also acquire that density which will prevent their 
further extension. While, however, the force oi' the heart 
and the quantity of the fluids, with respect to the whole 
system, remain the same, the distending and extending 
powers will be directed to such parts as have not yet ac- 
quired the same density and dimensions as those first evolv- 
ed ; and thus the distending and extending powers will pro- 
ceed to operate till every part of the system, in respect of 
density and resistance, shall have been brought to be in ba- 
lance "with every other, and till the whole be in balance 
with the force of the heart, so that there can be no further 
growth in any particular part, unless some preternatural cir- 
cumstance shall happen to arise. 

754.] In this process of the growth of the body, as it 
seems in general to depend upon a certain balance between 
the force of the heart or distending power, and the resist- 
ance of the solids ; so it will appear, that, while the solids 
remain very lax and yielding, some occasional increase of 
the distending power may arise without producing any very 
perceptible disorder in the system. But, it will also appear, 
that, in proportion as the distending power and resistance 
of the solids come to be more nearly in exact balance with 
one another, so any increase of the distending power will 
more readily produce a rupture of vessels, which do not 
easily yield to extension. 

755.'] From all this, it must follow, that the effects of 
any unusually plethoric state of the system, will be differ- 
ent according as this shall occur at different periods of the 
growth of the body. Accordingly, it is evident that if the 
plethoric state arises while the head is yet growing, and 
while the determination of the blood is still more to the head 
than to the other parts, the increased quantity of the blood 
will be especially determined to the head ; and as there also, 
at the same time, the balance between the distending and 
extending poweis is most nearly adjusted, so the determi- 
nation of°the blood will most readily produce in that part 
a rupture of the vessels, or an hemorrhagy. Hence it is, 
that hemorrhagies of the nose so frequently happen to 
young persons ; and in these more readily, as they approach 
nearer to their acme, or full growth ; or, it may be said, 
perhaps more properly, as they approach nearer to the 
acre of puberty, when!i perhaps, in both sexes, but espe- 
cfally in the female, a new determination arises in the system. 

75G.I The determination of a greater quantity of blood 



PRACTICE OF PHYSIC. 245 

to the vessels of the head, might be supposed to occasion a 
rupture of vessels in other parts of the head, as well as in 
t!j * nose : but such a rupture does not commonly happen ; 
because in the nose there is, for the purpose of sense, a 
considerable net-work of blood-vessels expanded on the in- 
ternal surface of the nostrils, and covered only with thin and 
weak teguments. From this circumstance it is, that upon 
any increased impetus of the blood in the vessels of the head, 
those of the nose are most easily broken ; and the effusion 
from the nose taking place, it not only relieves the other 
extremities of the external carotid, to which the arteries of 
the nose chiefly belong, but relieves also, in a great mea- 
sure, the system of the internal carotid. For, from the in- 
ternal carotid, certain branches are sent to the nose, are 
spread out on its internal surface, and probably inosculated 
with the extremities of the external carotid : so that, which- 
soever of the extremities are broken, the vis derivationis of 
Haller will take place ; the effusion will relieve the whole 
sanguiferous system of the head, and the same effusion will 
also commonly prevent an hemorrhagy happening at the 
^rae time in any other part of the body. 

757.] From these principles, it will appear why hemor- 
rhagies of the nose, so frequent before the period of puber- 
ty, or of the acme, seldom happen after these periods : 
and I must observe further, that although they should occur, 
they would not afford any objection to my doctrine, as such 
hemorrhagies might be imputed to a peculiar laxity of the 
vessels of the nose, and perhaps to a habit acquired with 
respect to these vessels, while the balance of the system 
might be otherwise duly adjusted. 

758.] When the-process of the growth of the body goes 
on regularly, and the balance of the system is properly ad- 
justed to the gradual growth of the whole, as well as to 
the successive growth of the several parts, even a plethoric 
state does not produce any hemorrhagy, or at least any af- 
ter that of the nose : but if, while the plethoric state con- 
tinues, any inequality shall also subsist in any of the parts 
of the system, congestions, hemorrhagic or inflammatory, 
may be still readily formed. 

759.] In general, it may be observed, that, when the se- 
veral parts of the system of the aorta have attained their 
full growth, and are duly balanced with one another, if then 
any considerable degree of plethora remain or arise, the 
nicety of the balance will be between the symptoms of the 

2i 



246 PRACTICE OF PHYSIC. 

aorta and pulmonary artery, or between the vessels of the 
lungs and those of all the rest of the body. And although 
the lesser capacity of the vessels of the lungs is commonly 
compensated by the greater velocity of the blood in them ; 
yet, if this velocity be not always adjusted to the necessary 
compensation, it is probable that a plethoric state of the 
whole body will always be especially felt in the lungs ; and 
therefore, that an hemorrhagy, as the effect of a general 
plethora, may be frequently occasioned in the lungs, even 
though there be no fault in their conformation. 

760.] In some cases, perhaps, an hemorrhagy from the 
lungs, or an hemoptysis, does arise from the general ple- 
thoric state of the body ; but an hemoptysis more frequent- 
ly does, and may be expected to happen, from a faulty 
proportion between the capacity of the lungs and that of 
the rest of the body. 

761.] When such a disproportion takes place, it will be 
evident, that an hemoptysis will especially happen about 
the time that the body is approaching to its acme ; that is, 
when the system of the aorta has arrived at its utmost ex- 
tension and resistance, and when, therefore, the plethoric 
state of the whole must especially affect the lungs. 

762.] Accordingly, it lias been constantly observed, that 
the hemoptysis especially occurs about the time of the bo- 
dy's arriving at its acme ; but I must remark also, that the 
hemorrhagy may occur sooner or later, according as the ba- 
lance between the vessels of the Jungs, and those of the 
system of the aorta, happens to be more or less exactly ad- 
justed to one another ; and it may therefore often occur 
much later than the period mentioned, when that balance, 
though not quite even, is however not so ill adjusted, but 
that some other concurring causes are necessary to give it 
effect. 

763.] It was anciently remarked by Hippocrates, and 
has been confirmed by modern observation, that the hemop- 
tysis generally occurs in persons between the age of fifteen 
and that of five and thirty ; that it may happen at any time 
between these two periods ; but that it seldom happens be- 
fore the former, or after the latter ; and it may be proper 
here to inquire into the reason of these two limitations. 

764.] With respect to the first, the reason of it has been 
already explained in 761, and 762. 

With respect to the second limitation, I expect that the 



PRACTICE OF PHYSIC. 247 

reason of it will be understood from the following consi- 
derations. 

It has been already observed, that the extension and 
growth of the body require the plethoric state of the ar- 
terial system ; and nature has provided for this, partly by 
the constitution of the blood being such that a great por- 
tion of it is unfit to pass into the exhalents and excretories ; 
partly by giving a certain density and resistance to the seve- 
ral exhalents and excretories through which the fluids might 
pass out of the red arteries ; and partly, but especially, 
by a resistance in the veins to the free passage of the blood 
into them from the arteries. 

765.] With respect to this last and chief circumstance, 
it appears from the experiments of Sir Clifton Wintring- 
ham, in his Experimental Inquiry, that the proportional 
density of the coats of the veins to that of the coats of the 
arteries, is greater in young than in old animals: From 
which it may be presumed, that the resistance to the pas- 
sage of the blood from the arteries into the veins, is great- 
er in young animals than in old ; and, while this resistance 
continues, the plethoric state of the arteries must be con- 
stantly continued and supported. As however the density 
of the coats of the vessels consisting chiefly of a cellular 
texture, is increased by pressure; so, in proportion as the 
coats of the arteries are more exposed to pressure by dis- 
tension than those of the veins, the former, in the progress 
of the growth of the body, must increase much more in 
density than the latter; and, therefore, the coats of the ar- 
teries, in respect of density and resistance, must come, in 
time, not only to be in balance with those of the veins, 
but to prevail over them: a fact which is sufficiently prov- 
ed by the experiments of the above mentioned ingenious 
author. 

By these means, the proportional quantities of blood in 
the arteries and veins must change in the course of life. In 
younger animals the quantity of blood in the arteries must 
be proportionally greater than in old ones; but by the in- 
creasing density of the arteries, the quantity of blood in 
them must be continually diminishing, and that in the veins 
be proportionally increasing, so as at length to be in a pro- 
portionally greater quantity than that in the arteries. 
When this change happens in the proportional quantities 
of the blood in the arteries and veins, it must be evident 
that the plethoric state of the arteries will be in a great 



248 PRACTICE OF PHYSIC. 

measure taken off; and therefore that the arterial hemor- 
rhagy is no longer likely to happen ; but that if a general 
plethoric state afterwards take place in the system it must 
especially appear in the veins. 

766.] The change I have mentioned to happen in the 
state of the arterial and venous systems, is properly sup- 
posed to take place in the human body about the age of 
thirty-live, when it is manifest that the vigor of the body, 
which depends so much upon the fulness and tension of the 
arterial system, no longer increases ; and therefore it is 
that the same age is the period, after which the arterial he- 
morrhagy, hemoptysis, hardly ever appears. It is true, 
there are instances of the hemoptysis happening at a later 
period; but it is for the reasons given (757.) which show 
that an hemorrhagy may happen at any period of life, from 
accidental causes forming congestions, independent of the 
state of the balance of the s} r stem at that particular period. 

767.] I have said (765.) that if after the age of thirty- 
five, a general and preternatural plethoric state occur, it 
must especially appear in the venous system ; and I must 
now observe, that this venous plethora may also give oc- 
casion to hemorrhagy. 

76 8.] If a plethoric state of the venous system take place, 
it is to be presumed, that it will especially and in the first 
place affect the system of the vena portarum, in which the 
motion of the venous blood is more slow than elsewhere ; 
in which the motion of the blood is little assisted by exter- 
nal compression ; and in which, from the want of valves 
in the veins that form the vena portarum, the motion of the 
blood is little assisted by the compression that is applied; 
while, from the same want of valves in those veins, the 
blood is more ready to regurgitate in them. Whether any 
regurgitation of the blood can produce an action in the 
veins, and which inverted, or directed towards their ex- 
tremities, can force these, and occasion hemorrhagy, may 
perhaps be disputed : but it appears to me that an hemor- 
rhagy, produced by a plethoric state of the veins, may be 
explained in another and more probable manner. If the 
blood be accumulated in the veins, from an interruption of 
its proper course, that accumulation must resist the free pas- 
sage of the blood from the arteries into the veins. This 
again must produce some congestion in the extremities of 
the red arteries, and therefore some increased action in 
them, which must be determined with more than usual 



PRACTICE OF PHYSIC. 249 

force, both upon the extremities of the arteries, and upon 
the exhalants proceeding from them ; and this force may 
occasion an effusion of blood, either by anastomosis or 
rupture. 

760.] In this manner I apprehend the hemorrhoidal flux 
is to be explained, so far as it depends upon the state of the 
whole system. It appears most commonly to proceed from 
the extremities of the hemorrhoidal vessels, which, being 
the most dependent and distant branches of those veins that 
form the vena portarum, are therefore the most readily af- 
fected by every accumulation of blood in that system of 
veins, and consequently by any general plethora in the ve- 
nous system. 

770.] It is here to be observed, that I have spoken of this 
hemorrhagy as proceeding from the hemorrhoidal vessels 
only, as indeed it most commonly does ; but it will be rea- 
dily understood, that the same accumulation and resistance 
to the venous blood may, from various causes, affect many 
of the extremities of the vena portarum, which lie very su- 
perficially upon the internal surface of the alimentary canal, 
and give occasion to what has been called the Morbus Niger 
or Melasna. 

771.] Another part in which an unusually plethoric state 
of the veins may have particular effects, and occasion bemor- 
rhagy, is the head. In this, the venous system is of a pecu- 
liar conformation, and such as seems intended by nature to 
give there a slower motion to the venous blood. If, there- 
fore, the plethoric state of the venous system in general, 
which seems to increase as life advances, should at length 
increase to a great degree, it may very readily affect the 
venous vessels of the head, and produce there such a resist- 
ance to the arterial blood, as to determine this to be poured 
out from the nose, or into the cavity of the cranium. The 
special effect of the latter effusion will be, to produce the 
disease termed Apoplexy ; and which, therefore, is pro- 
perly named by Doctor Hoffman, liamorrhagia Cerebri: 
and the explanation of its cause, which I have now given, 
explains well why it happens especially to men of large 
heads and short necks, and to men in the decline of life, when 
the powers promoting the motion of the blood are much 
weakened. 

772.] I have thus attempted to give the history of the 
plethoric and hemorrhagic states of the human body, as 
they occur at the different periods of life ; and hope I have 



250 PRACTICE OF PHYSIC. 

thereby explained, not only the nature of hemorrhagy in 
general, but also of the particular hemorrhagies which most 
commonly appear, and as they occur successively at the dif- 
ferent periods of life. 



SECTION III. 

Of the Remote Causes of Hemorrhagy. 

773.] IN the explanation hitherto given, I have especially 
considered the predisposition to hemorrhagy ; but it is pro- 
per also, and even necessary, to take notice of the occa- 
sional causes, which not only concur with the predisponent, 
in exciting hemorrhagy, but may also sometimes be the sole 
causes of it. 

774.] These occasional causes are, 

1. External heat, which, by rarefying the blood, produ- 
ces or increases the plethoric state of the body ; and the 
same heat, as giving a stimulus to the whole system, must 
urge any particular determinations before established, still 
further, or may urge to excess any inequality, otherwise 
innocent ; so that, in either way, external heat may imme- 
diately excite hemorrhagies, to which there was a predispo- 
sition, or may form congestions where there were none be- 
fore, and thereby occasion hemorrhagy. 

2. A'considerable and sudden diminution of the weight of 
the atmosphere, which seems to occasion the same effects 
as heat, by producing also an expansion of the blood. 

3. Whatever increases the force of the circulation, and 
thereby the velocity of the blood, may operate in the same 
manner as heat, in urging not only previous determinations 
with violence, but also in urging to excess inequalities, 
otherwise innocent. All violent exercise, therefore, and es- 
pecially all violent efforts, which, not only by a larger and 
longer inspiration, but also by the simultaneous action of 
many muscles interrupting the free motion of the blood, 
impel it with unusual force into the extreme vessels more ge- 
nerally, and, according to the different postures of the body, 
and mode of the effort, into certain vessels more particularly. 

Among the causes increasing the force of the circulation, 
anger* and other violent active passions are to be reckoned. 

* Passionate children frequently bring on a bleeding of the nose ; and when sikIi an accident 
happens, the chiid\ face, before the blood breaks cut, becomes red, and all the vest 
fcciu and neck seem distended and full. 



PRACTICE OF PHYSIC. 251 

4. The violent exercise of particular parts of the body. 
If these are already affected with congestions, or liable to 
them, such exercise may be considered as a stimulus ap- 
plied to the vessels of that particular part. Thus, any vio- 
lent exercise of respiration* may excite hemoptysis, or oc- 
casion its return. 

5. The postures of the body increasing determinations, 
or ligatures occasioning accumulations of the blood in par- 
ticular parts of the body. 

6. A determination into certain vessels rendered habitual 
by the frequent repetition of hemorrhagy from them. 

7. Cold, externally applied, as changing the distribution 
of the blood, and determining it in greater quantity into 
the internal parts. 



SECTION IV. 

Of the Cure of Hemorrhagy. 

T75.] HAVING thus considered the proximate and re- 
mote causes of hemorrhagy in general, our next business is, 
to treat of the cure of the disease in the same manner. 

In entering upon this subject, the first question -which 
presents itself, is, Whether the cure of hemorrhagies ought 
to be attempted by art, or if they should be left to the con- 
duct of nature ? 

776.J The latter opinion was the favorite doctrine of the 
celebrated Dr. Stahl, and his followers. They maintained, 
that the human body is much disposed to a plethoric state ; 
and, consequently, to many disorders which nature endea- 
vors to obviate and relieve by exciting hemorrhagy : that 
this, therefore, is often necessary to the balance and health of 
the system : that it is accordingly to be generally encou- 
raged, sometimes solicited, and is not to be suppressed, un- 
less when it goes to great excess, or happens in parts in which 
it may be dangerous. 

1T7.] Much of this doctrine may be admitted. The hu- 
man body, upon many occasions, becomes preternaturally 
plethoric ; and the dangerous consequences which might 
from thence be apprehended, seem to be obviated by an he- 
morrhagy taking place : and, further, the necessity of he- 

* As playing «n the German flute, or any other wind instrument that requires a great force 
to blow it. 



252 PRACTICE OF PHYSIC. 

morrhagy often appears from hence, that the suppression 
of jt seems to occasion many disorders. 

All this seems to be just ; but, in the conclusion drawn 
from it, there is a fallacy. 

718.] It appears to me certain, that hemorrhagy, either 
upon its first attack, or upon its after recurrence, is never 
necessary to the health of the body, excepting upon the sup 
position, that the plethoric state which seems to require the 
evacuation, cannot be otherwise prevented or removed ; and 
as I imagine it possible by other means to prevent or remove 
a plethoric state, so I do not think that hemorrhagy is, in all 
cases, necessary. In general, I am of opinion, that hemor- 
rhagy is to be avoided. 

1 . Because it does not always happen in parts where it 
is safe. 

2. Because often, while it does relieve a plethoric state, 
it may, at the same time, induce a very dangerous disease. 

3. Because it may often go to excess, and either endan- 
ger life, or induce a dangerous infirmity. 

And, lastly, Because it has a tendency to increase the 
plethoric state it was meant to relieve ; to occasion its own 
recurrence (720.) and thereby to induce a habit, which, if 
left to the precarious and unequal operation of nature, may 
from the frequent errors of this, be attended with much 
danger. 

779.] It is further to be considered, that heinorrhagies 
do not always arise from the necessities of the system, but 
often proceed from incidental causes. It appears to me that 
all hemorrhagies of the latter kind may be immediately 
suppressed, and the repetition of them, as it induces a ple- 
thora, and a habit not otherwise necessary, may be pre*, 
vented with great advantage. 

780.] Upon the whole of this subject, I conclude, that 
every preternatural hemorrhagy, or, in other words, every 
one except that of the menses in females, is to be avoided, 
and especially the returns of it prevented ; and I therefore 
now proceed to mention, how hemorrhagy, and its recur- 
rences, may, and should be prevented. 

78 1 .] From the principles delivered above, it will imme- 
diately appear, that the prevention, either of the first at- 
tacks, or of the returns of hemorrhagy, will chiefly, and 
in the first place, depend upon the preventing or removing 
any considerable degree of a plethoric state which may hap- 
pen to prevail in the body. It is true, that, where the he- 



PRACTICE OF PHYSIC. 253 

morrhagy depends upon the particular conformation of cer- 
tain parts, rather than upon the general plethoric state of 
the whole ; the measures for removing or preventing the 
latter, may not always be sufficient for preventing hemor- 
rhagy ; but at the same time it must be evident, that de- 
terminations, in consequence of the conformation of parti- 
cular parts, will always be urged more or Jess, in propor- 
tion to the greater or lesser degree of the plethoric state of 
the whole system ; and therefore, that, even in the cases 
depending upon particular conformation, the preventing 
or removing an unusual plethoric state, will always be a 
chief means of preventing hemorrhagy. It is further to 
be attended to, that there may be several inequalities in the 
balance of the system, which may have little or no effect 
unless when the system becomes preternaturally plethoric ; 
and therefore, that, in all cases, the preventing or remov- 
ing of the plethoric state of the system, will be a chief 
means of preventing the first attacks, or the returns of he- 
morrhagy. It now, therefore, remains to explain, how the 
plethoric state of the system is to be prevented or removed. 

782.] The fluids of the human body are in continual 
waste by the excretions, but are commonly replaced by the 
aliments taken in ; and if the quantity of aliments in any 
measure exceed that of the excretions, an increase of the 
quantity of the fluids of the body, or, in other words, a 
plethoric state, must necessarily arise. This, to a certain 
degree, is requisite for the growth of the body, but, even 
then, if the proportion of the aliments to the excretions, be 
greater than is suited to the growth of the body, and more 
certainly still, if, after the growth is completed, when an 
equality between the ingesta and the excreta, should be es- 
tablished, the disproportion still continue, a preternaturally 
plethoric state must arise. In both cases, it is evident, 
that the plethora must be prevented or corrected by adjust- 
ing the ingesta and excreta to each other ; which generally 
may be done, either by diminishing the ingesta, or by in- 
creasing the excreta.* The former may be effected by the 
management of diet, the latter by the management of exer- 
cise. 

783.] The ingesta may be diminished, either by giving 
aliment in less quantity than usual, or by giving aliments 
of a less nutritious quality ; that is, aliments of a substance 
which under the same bulk and weight, contain less of a 

• Th« effect may surely be more speedily produced by using both these means at once. 

2k 



254 PRACTICE OF PHYSIC. 

matter capable of being converted into animal fluids, and 
more of a matter ready to pass off by the excretions, and 
consequently less of a matter to be retained and accumu- 
lated in the vessels. 

The choice of aliments suited to these purposes must be 
left to be directed by the doctrines of the Materia Medica. 

784.] The increasing of the excreta, and thereby dimi- 
nishing the plethoric state of the system, is to be obtained 
bv increasing the exercise of the body ; and generally for 
adjusting the balance between the ingesta and excreta, and 
thereby obviating the plethoric state, it is necessary that 
exercise, in a due measure, be very constantly employed.* 

785.] The observing abstinence, and the employment of 
exercise, for obviating or removing the plethoric state of 
the body, were formerly considered pretty fully, when 
treating of the gout, (547, to 551.) so that the less is ne- 
cessary to be said here : and it is now only requtsite to ob- 
serve, that the same doubts, as in cases of the gout do not 
occur here with regard to the safety of those measures, 
which, in a plethoric state of the body disposing to hemor- 
rhagy, are always admissible and proper. Here, however, 
it is to be observed, thut some choice in the mode of exer- 
cise is necessary, and that it should be different according 
to the particular determinations which may happen to pre- 
vail in the system. In general, in the case of plethora dis- 
posing to hemorrhagy, bodily exercise will always be ha- 
zardous, and gestation more commonly safe. 

786.] Artificial evacuations may be employed to dimi- 
nish the plethoric state of the body : and when, at any 
time, it has become considerable, and immediately threat- 
ens a disease, these evacuations should be made to the quan^ 
tity that the symptoms seem to require. But it is constant- 
ly to be attended to, that blood-lettings are improperly em- 
ployed to prevent a plethora, as they have a tendency to in- 
crease it (720.) and as they require to be often repeated, 
and are thereby apt to induce a habit which may be attend- 
ed with much danger.f 

• The exercise best adapted to these cases is such as does not heat the body or increase the 
force of the blood. Hence riding moderately, travelling in a carriage, or sailing, are preterabln 
to walking. Young people may use such gentle exercise as may amuse the mind, and at the 
same time conduce to bodily health, as gardening, several agricultural labors, or mechanical 
operations ; or some of the sports that require a gentle bodily exertion, as bowling, archery, &c. 

+ Brisk purges are perhaps preferable to every other mode of evacuating the ingesta ; and ii> 
these cases we may have recourse to drastics without any apprehension of danger. 'Ihe fol- 
lowing formula" may serve as specimens of the purges u:ciul in these cases. 

Be. Pulv. Rad. Jalap. §fr. 
Aromat. 3i. 



PRACTICE OF PHYSIC. 235 

787.] While a plethora, and thereby the predisposition 
to hemorrhagy, is avoided, or removed, the other mea- 
sures necessary for preventing the occurrence of this, are 
those for avoiding the remote causes. These have been 
enumerated in 774, and the means of avoiding them, so far 
as within our power, are sufficiently obvious. 

788.] Having thus mentioned the means of preventing 
either the first attacks, or the recurrence of hemorrhagy ; 
I must next say how it is to be managed when it has actu- 
ally come on. 

789.] When an hemorrhagy has come on which appears 
to have arisen from a preternatural ly plethoric state, or from 
some change in the balance of the sanguiferous system, no 
measures are to be immediately taken for suppressing it ; as 
we may expect, that, when the quantity of blood necessary 
for the relief of the system is poured out, the effusion wiii 
spontaneously cease.* 

790.] In many cases however, it may be suspected, that 
the quantity of blood poured out, is not exactly in propor- 
tion to the necessities of the system, either for relieving a 
general plethora or a particular congestion, but that it is 
often to a greater quantity than these require. This we 
suppose to happen in consequence of an inflammatory dia- 
thesis prevailing, and of a febrile spasm being formed ; and 
therefore it is in many cases proper, as well as for the most 

Sal. Tart. 3 ft. 
Syr. Simp. q. s. 
M. f. Elect. 

This electuary may be divided into four doses, one of which may be taken «arly in the morn, 
ing, as occasion may require. 

R. Pilul. Rust, 3 ft- 
Calomel, gr. vi. 
Syr. Simpl. q. s. 
M. f. Massa in pilulas equales sex dividend. 

I these pills may be taken in the evening, and the remaining tour the following moru- 

R. Resin. Jalap. 9i. 

Tere in mortar, cum Sacch. alb. 3 ft- 
Amygdal. dulc. decorticat. No. ii. 
Adde gradatim Aq. Cinnamom. simpl. Si. 
M. f. haust. mane sumend. 

TUSs is a very elegant puree, and has the peculiar advantage of operating powerfully without 
<r occasioning much inconvenience. 

•The doctrine here delivered, and the practice founded on it, is pure Stahlianism ; and is, 
doubtless, in these cases the best practice. A patient, however, is not always satisfied when 
(he physician is inactive, which often obliges him to prescribe some of the medicamenta iu- 
ertiora, and the choice of them must be lelt to the practitioner's own sagacity. 



2 56 PRACTICE OF PHYSIC. 

part safe, to moderate the evacuation, and, when it threat- 
ens to go to excess, to suppress it altogether. 

791.] An hemorrhagy may be moderated by avoiding 
any irritation that might concur to increase it ; so that every 
part of the antiphlogistic regimen is to be observed ; in par- 
ticular, external heat, both as it rarefies the fluids, and sti- 
mulates the solids, is to be carefully avoided : and, it is 
probable, that in all cases an hemorrhagy may be safely 
moderated by cool air applied, and cold drink exhibited. 

792.] A second means for the same purpose, is, the use 
of refrigerant medicines, and particularly of acids and nitre.* 

793.] A third means which has been frequently employ- 
ed, is that of blood-letting. The propriety of this prac- 
tice may be doubtful, as the quantity of blood poured out 
by the hemorrhagy, may be supposed to answer the purpose 
of an evacuation in any other way ; and I am ready to al- 
low, that the practice has been often superfluous, and some- 
times hurtful, by making a greater evacuation than was ne- 
cessary or safe. At the same time, 1 apprehend it is not for 
the mere purpose of evacuating, that blood-letting is to be 
practised in the cure of hemorrhagy ; but that it is further 
necessary for taking oft' the inflammatory diathesis which 
prevails, and the febrile spasm that has been formed. Ac- 
cordingly, in the case of hemorrhagy, when the pulse is not 
only frequent, but quick and full, and does not become softer 
or slower upon the flowing of the blood, and that the effu- 
sion is profuse, and threatens to continue so, it appears to 
me, that blood-letting may be necessary, and I have often 
found it useful. It seems probable also, that the particular 
circumstances of venesection may render it more powerful 
for taking off the tension and inflammatory irritation of the 
system, than any gradual flow from an artery. 

794.] That a spasm of the extreme vessels has a share in 
supporting hemorrhagy, appears to me probable from hence, 
that blistering has been often found useful in moderating and 
suppressing the disease. 

795.] Do emetics and vomiting contribute to the cure of 

* The refrigerant medicines have been enumerated in former notes, articles 131. and 135. 
The Tinctura rosarum is a very proper acid lelngerant in most hemorrhagies. The dose of it 
must be proportioned to the exigency of the case ; it ought neter to exceed tour ounces in the 
space or an hour ; an ounce every half hour is generally sufficient, and a greater quantity at a 
tune frequently occasion, gripes, and by its irritation increases the disease : especially if it does 
not produce a diarrhcea which is seldom the case. With respect to nitre, die precautions, men- 
tioned in the note on article 135, must be observed. The dulcified spirit ot vitriol or of nitre, 
are nut alwavs safe medicines in these cases, as they heat and irritate. The acid of tartar, in the 
form described in the note on article 13+. auiwers very well in most cases. 



PRACTICE OF PHYSIC. 257 

hemorrhagy ? see Dr. Bryan Robinson on the virtues and 
power of medicines. 

796.] When an hemorrhagy is very profuse, and seems 
to endanger life, or even threatens to induce a dangerous 
infirmity, it is agreed on all hands, that it is to be immedi- 
ately suppressed by every means in our power, and particu- 
larly that, besides the means above-mentioned for moderat- 
ing the disease, astringents, internal or external, where the 
latter can be applied, are to be employed for suppressing it. 

797.] The internal astringents are either vegetable or 
fossil. 

The vegetable astringents, are seldom very powerful in 
the cure of any hemorrhagies, except those of the alimen- 
tary canal. 

The fossil astringents are more powerful; but soma 
choice amongst the different kinds may be proper. 

The chaly beats, so frequently employed, do not appear 
to me to be very powerful. 

The preparations of lead are certainly more so, but are 
otherwise of so pernicious a quality, that they should not 
be employed except in cases of the utmost danger. The 
Tinctura Saturnina, or Antiphthisica, as it has been called, 
appears to be of little efficacy;* but whether from the 
small portion of lead which it contains, or from the state 
in which the lead is in it, I am uncertain. 

The fossil astringent that appears to me the most power^ 
ful, and at the same time the most safe, is alum.f 

798.] External astringents, when they can be applied, 
are more effectual than the internal. The choice of these 
is left to the surgeons. 

799.] The most powerful of all astringents appears to 
me to be cold, which may be employed, either by ap- 
plying cold water to the surface of the body, or by throw- 
ing it into the internal parts. £ 

800.] For suppressing hemorrhagies, many superstitious 
remedies and chavms|| have been recommended, and pre- 

» It is a very dangerous medicine, and ought to be used with the utmost caution. But since 
its efficacy is doubiiul, we had better abandon it altogether, except when every other remedr 
rails. 

+ Alum frequently irritates if given in too large doses at first, proving sometimes a purgative 
and sometimes an emetic. In cases of great danger, however, it must be given in large quan- 
tlttea by frequently repeating small doses. Five grains is a sufficient dose to begin with; but it 
may !><■ repeated every hour, or every half hour. Some authors have given it in doses of a scru- 
ple several times a day ; hut that is certainly too great a quantity at once. 

t Van Swicten relati ai die nose being stopped by the application of 

pledgets dipped in cold wine and water, to the scrotum ; a shivering was produced, and the 
bleeding stopped. 

.'.onishing that these charm* should continue in use in this enlightened age. Tliey arc 
practised among the country people frequently. Some of ihem, however, act mechanically, as 
the application of the great key of the church door to the nape of the neck, in bleediafis at the 



255 PRACTICE OF PHYSIC. 

tended to have been employed with success. The seeming 
success of these, however, has been generally owing to the 
by-standers' mistaking a«spontaneous ceasing of the hemor- 
rhagy for the effect of the remedy. At the same time, I 
believe, that those remedies may have been sometimes use- 
ful, by impressing the mind with horror, awe, or dread. 

801.] Upon occasion of the profuse hemorrhagies, opi- 
ates have been employed with advantage; and, when the 
fulness and inflammatory diathesis of the system have been 
previously taken off by the hemorrhagy itself, or by blood- 
letting, I think opiates may be employed with safety.* 

802] For restraining hemorrhagy, ligatures have been 
applied upon the limbs, in the view of retarding the return 
of the venous blood from the extremities ; but they ap- 
pear to me to be of uncertain and ambiguous use. 

803.] In the case of profuse hemorrhagies, no pains are 
to be taken to prevent a Deliquium Animi, or fainting, as 
the happenning of this is often the most certain means of 
stopping the hemorrhagy. f 

804. Having thus delivered the general doctrine of he- 
morrhagy, I proceed to consider the particular cases of it. 
It may perhaps be remarked, that 1 have marked fewer of 
these than are commonly enumerated by the nosologists ; 
but my reasons for differing from these authors, must be 
left to a nosological discussion, to be entered into elsewhere 
more properly than here. 



CHAPTER IL 

OF THE EPISTAXIS, OR HEMORRHAGY OF 
THE NOSE. 

805.] f "P , HE state of the vessels upon the internal sur- 
JL face of the nose being such as already men- 
tioned (757.) renders an hemorrhagy from that more fre- 
quent than from any other part of the body. 

806.] The blood commonly flows from one nostril only ; 

nose j drinking large draughts of cold water out of a human skull, &c. The cold iron and the 
cold water were in fact proper remedies. 

♦Opium, however, ought to be cautiously avoided in active hemorrhagies, which are fre- 
quently ac jmpjmed wnn :i phlogistic diathesis ; and it is well known, that in such a diathesis, 
opium is gen^r : ersally, hurtful. But, as the author observes, when the hcmor- 

iiifljinmatory diathesis, we may then give opium freely; and for this 
purpose Lai ge doses aie preferable to ".mailer ones. 

+ Attention, however, is neces.ai j in this case, as fainting is frequently the forerunner of death. 



PRACTICE OF PHYSIC. 259 

and probably, because an hemorrhagy from one vessel re- 
lieves the congestion in all the neighboring vessels. 

The blood flowing from both nostrils at the same time, 
shows commonly a more considerable disease. 

807.] This hemorrhagy happens to persons of every 
constitution and temperament, but most frequently to those 
of a plethoric habit and sanguine temperament. It hap- 
pens to both sexes, but most frequently to the male. 

808.] This hemorrhagy may occur at any time of life ; 
but most commonly happens to young persons, owing to 
the state of the balance of the system peculiar to that age, 
as mentioned in 755. 

809.] Although generally it happens to persons before 
they have arrived at their full growth, and more rarely 
afterwards; yet sometimes it happens to persons after their 
acme, and during the state of manhood : And it must then 
be imputed to an unusually plethoric state of the system ; 
to an nabitual determination of the blood to the vessels of 
the nose ; or to the particular weakness of these. 

810.] In all these cases the disease may be considered as 
an hemorrhagy purely arterial, and depending upon an ar- 
terial plethora ; but it sometimes occurs in the decline of 
life, when probably it depends upon, and may be consi- 
dered as a mark of a venous plethora of the vessels of the 
head. See 771. 

811.] This hemorrhagy happens also at any period of 
life, in certain febrile diseases, which are altogether or 
partly of an inflammatory nature, and which show a par- 
ticular determination of the blood to the vessels of the 
head. These diseases often admit of a solution by this 
hemorrhagy, when it may be properly termed critical. 

812.] The disease sometimes comes on without any pre- 
vious symptoms ; particularly, when some external vio- 
lence has a share in producing it. But, when it proceeds 
entirely from an internal cause, it is commonly preceded 
by headachs, redness of the eyes, a florid color of the 
face, an unusual pulsation in the temples, a sense of ful- 
ness about the nose, and an itching of the nostrils. A 
bound belly, pale urine, coldness of the feet, and cold shi- 
vering over the whole body, are also sometimes among the 
symptoms that precede the disease. 

813.] From the weakness of the vessels of the nose, the 
blood often flows from them without any considerable ef- 
fort of the whole system, and therefore without any ob- 



260 PRACTICE OF PHYSIC. 

servable febrile disorder ; which, however, in many cases, 
is, in all its circumstances, very discernible. 

814.] An hemorrhagy of the nose happening to young 
persons, is, and may generally be considered, as a slight 
disease of little consequence, and hardly requiring any re- 
medy. But, even in young persons, when it recurs very 
frequently, and is very copious, it will require particular 
attention, as it is to be considered as a mark of arterial 
plethora ; and, as frequently returning, it may increase the 
plethoric state ; which, in a more advanced stage of life, 
may give the blood a determination to parts from which 
the hemorrhagy would be more dangerous. All this will 
more particularly require attention, according as the 
marks of plethora, and of particular congestion, preced- 
ing the hemorrhagy, are more considerable ; and as the 
flowing of the blood is attended with a more considerable 
degree of febrile disorder. 

315.] When the epistaxis happens to persons after their 
acm6, returning frequently, and flowing copiously, it is 
always to be considered as a dangerous disease, and as 
more certainly threatening the consequences mentioned in 
the last paragraph. 

816.] When this hemorrhagy happens in the decline of 
life, it may be considered as in itself very salutary : but at 
the same time, it is to be considered as a mark of a very 
dangerous state of the system; that is, as a mark of a very 
strong tendency to a venous plethora in the vessels of the 
head : and I have accordingly observed it often followed 
by apoplexy, palsy, or such like diseases. 

817.] When an hemorrhagy from the nose happens in 
febrile diseases, as mentioned in 811, and is in pretty large 
quantity, it maybe considered as critical and salutary; but 
it is very apt to be profuse, and even in this way dangerous. 

It upon some occasions occurs during the eruptive fever 
of some exanthemata, and in such cases sometimes sa- 
lutary ; but, if these exanthemata be accompanied with 
any putrid tendency, this hemorrhagy, like artificial blood- 
lettings, may have very bad effects. 

818.] Having thus explained the several circumstances 
of epistaxis, I proceed to consider the management and 
cure of it. I use the expression of management, because 
it has been usually thought to require no cure, but that 
nature should be allowed to throw out blood in this way 
very frequently, and as often as it appears to arise from 



PRACTICE OF PHYSIC. 261 

internal causes, that is, from a state of the system sup- 
posed to require such evacuation. 

819. J I am however, of opinion, for the reasons given 
in 778. that this disease is very seldom to be left to the 
conduct of nature ; and that in all cases it should be mo- 
derated bv keeping the patient in cool air; by giving cold 
drink ; by keeping the body and head erect ; by avoiding 
any blowing of the nose, speaking, or other irritation : 
And, when the blood has flowed for some time, without 
showing any tendency to cease, a profuse bleeding is to be 
prevented by measures employed to stop it, such as pres- 
sing the nostril from which the blood flows, washing the 
face with cold water, or applying this to other parts of the 
body. 

820.] Even in the case of young persons, where the dis- 
ease is least hazardous, and even in the first attacks, I judge 
such measures to be proper ; but they will be still more 
proper if the disease frequently recurs without any external 
violence ; if the returns shall happen to persons of a habit 
disposed to be plethoric ; and more particularly, if the marks 
of a plethoric state appear in the precedent symptoms (8 12.) 

821.] Even in young persons, if the bleeding be very 
profuse and long continued, and more especially if the 
pulse become weak and the face pale, I apprehend it will 
be proper to suppress the. hemorrhagy by every means in 
our power. See 796, and following paragraphs.* 

822.] Further, in the same case of young persons, when 
the returns of this hemorrhagy become frequent, and es- 
pecially with the marks of a plethoric habit, I think it ne- 
cessary to employ such a regimen as may prevent a pletho- 
ric state, (782. 786.) At the same time, care should be 
taken to avoid all circumstances which may determine the 
blood more fully to the vessels of the head, or prevent its 
free return from them; and, by keeping an open belly to 
make some derivation from them.f 

823.] In adult persons liable to frequent returns of the 
epistaxis, the whole of the measures proposed (822.) are 
more certainly and freely to be employed. When, with 
the circumstances mentioned in 812, the tendency to a pro- 

» Beside the general directions referred to above, plugs of lint or cotton, impregnated with 
vinegar and a solution of alum, are recommended. Tnick cotton threads, impregnated with 
these styptic solutions, have been passed through the nostril, and brought out by the mouth by 
means or a bent probe, with great success. 

+ For this purpose Glauber's salt seems peculiarly adapted. It operates speedily, and without 
too much irritation ; evacuating at the same times, iwt only the contents of the intestinal Ci'.nai, 
hut the superfluities of the sanguiferous system. 

2l 



262 PRACTICE OF PHYSIC. 

fuse hemorrhagy appears, a bleeding at the arm may he 
proper, even in young persons ; but in the case of adults, 
it will be still more allowable, and even necessary. 

824.] In persons of any age liable to frequent returns 
of this hemorrhagy, when the measures proposed in 816. 
et. seq. shall have been neglected, or from peculiar circum- 
stances in the balance of the system, shall have proved in- 
effectual, and the symptoms threatening hemorrhagy (817.) 
shall appear, it will then be proper, by blood-letting, cool- 
ing purgatives, and every part of the antiphlogistic regi- 
men, to prevent the hemorrhagy, or at least to prevent its 
being profuse when it does happen. 

825.] In the circumstances just now mentioned (824.) 
the measures proposed are proper, and even necessary; 
but it should at the same time be observed, that these are 
practised with much less advantage than those pointed out 
in 823 ; because, though those suggested here may pre- 
vent the coming on of the hemorrhagy for the present, 
thev certainly however dispose to the return of that ple- 
thoric state which required their being used ; and there 
can be no proper security against returns of the disease, 
but by pursuing the means proposed in 822. 

826.] When the hemorrhagy of the nose happens to 

Eersons approaching their full growth, and when its returns 
ave been preceded by the symptoms (812.) it may be sup- 
posed, that, if the returns can be prevented by the mea- 
sures proposed in 824, these may be safely employed; as 
the plethoric state induced will be rendered safe, by the 
change which is soon to take place in the balance of the 
system. This, however, cannot be admitted ; as the eva- 
cuations practised upon this plan will have all the conse- 
quences which, I have already observed, may follow the 
recurrence of the hemorrhagy itself. 

827.] When the hemorrhagy of the nose shall be found 
to make its returns at nearly stated periods, the measures 
for preventing it (824.) may be practised with great cer- 
tainty ; and, upon every repetition of blood-letting, by di- 
minishing the quantity taken away, its tendency to induce 
a plethora may be in some measure avoided. When in- 
deed, the repetition of evacuations is truly unavoidable, 
the diminishing them upon every repetition is properly 
practised ; but it is a practice of nice and precarious ma- 
nagement, and should by no means be trusted to, so far 



PRACTICE OF PHYSIC. 263 

as 10 supersede the measures proposed in 824, wherever 
these can be admitted. 

823.] When the hemorrhagy of the nose happens in 
consequence of a venous plethora in the vessels of the head, 
as in 771. the flowing of the blood pretty largely may 
be allowed, especially when it happens after the suppres- 
sion or ceasing of the menstrual or hemorrhoidal flux. 
But though the flowing of the blood is, on its first occur- 
ring, to be allowed, there is nothing more proper than 
guarding against its returns. This is to be done not only 
by the measures proposed in 782. et seq. but, as the ef- 
fects of a plethoric state of the vessels of the head are very 
uncertain ; so, upon any appearance of it, and especially 
upon any threatening of hemorrhagy, the plethora is to be 
removed, and the hemorrhagy to be obviated immediately 
by proper evacuations, as blood-letting, purging, and issues ; 
or by restoring suppressed evacuations, where this can be 
done. 



CHAPTER III. 

OF THE HEMOPTYSIS, OR HEMORRHAGY 
FROM THE LUNGS. 

SECTION I. 

Of the Phenomena and Causes of Hemoptysis. 

829.] TT7HEN, after some affection of the breasr, 
VV blood is thrown out from the mouth, and is 
brought out with more or less of coughing, there can be no 
doubt that it comes from the lungs ; and this generally as- 
certains the disease of which I am now to treat. But there 
are cases in which the source of the blood spit out is uncer- 
tain ; and therefore, some other considerations to be men- 
tioned hereafter, are often necessary to ascertain the exist- 
ence of an hemoptysis. 

830.] The blood-vessels of the lungs are more numerous 
than those of any other part of the body of the same bulk. 
These vessels, of the largest size, as they arise from the 
heart, are more immediately than in any other part subdi- 
vided into vessels or' the smallest size ; and these small ves- 
sels spread out near to the internal surfaces of the bronchial 



264 PRACTICE OF PHYSIC. 

cavities, are situated in a loose cellular texture, and cover- 
ed by a tender membrane only : so that, considering how 
readily and frequently these vessels are gorged with blood, 
we may understand why an heixiorrhagy from them is, next 
to that of the nose, the most frequent of any; and particu- 
larly, why any violent shock given to the whole body so 
readily occasions an hemoptysis. 

831.] An hemoptysis may be occasioned by external vio- 
lence, at any period of life ; and I have explained above 
(759.) why, in adult persons, while the arterial plethora 
still prevails in the system, that is, from the age of sixteen 
to that of five-and-thirty, an hemoptysis may at any time 
be produced, merely by a plethoric state of the lungs. 

832.] But it has been also observed above, (760.) that 
an hemoptysis more frequently arises from a faulty propor- 
tion between the capacity of the vessels of the lungs and 
that of the rest of the body. Accordingly it is often a he- 
reditary disease, which implies a peculiar and faulty con- 
formation. And the disease also happens especially to per- 
sons who discover the smaller capacity of their lungs, by the 
narrowness of their chest, and by ihe prominency of their 
shoulders ; which last is a mark of their having been long 
liable to a difficult respiration. 

833.] With these circumstances also the disease happens 
especially to persons of a sanguine temperament ; in whom, 
particularly, the arterial plethora prevails. It happens 
likewise to persons of a slender delicate make, of which a 
long neck is a mark ; to persons of much sensibility and ir- 
ritability, and therefore of quick parts, whose bodies are 
generally of a delicate structure ; to persons who have 
been formerly liable to frequent hemorrhagies of the nose ; 
to persons who have suffered a suppression of any hemorrha- 
gy they had formerly been liable to, the most frequent in- 
stance of which is in females who have suffered a suppression 
of their menstrual flux; and, lastly, to persons who have 
suffered the amputation of any considerable limb. 

834.] In most of these cases (833.) the disease happens 
especially to persons about the time of their coming to their 
full growth, or soon after it, and this for the reasons fully 
set forth above. 

835.] From all that has been said from 830, to 834, 
the predisponent cause of hemoptysis will be sufficiently 
understood, and the disease may happen from the mere cir- 
cumstance of the predisponent cause arising to a considera- 



PRACTICE OF PHYSIC. 265 

ble degree. In the predisposed, however, it is often brought 
on by the concurrence or various occasional and exciting 
causes. One of these, and perhaps a frequent one, is ex- 
ternal heat ; which, even when in no great degree, will bring 
on the disease in spring, and the beginning of summer, 
while the heat rarefies the blood more than it relaxes the 
solids which had been before contracted by the cold of 
winter. Another exciting cause is a sudden diminution of 
the weight of the atmosphere, especially when concurring 
with any effort in bodily exercise. This effort, too, alone, 
may often, in the predisposed, be the exciting cause ; and, 
more particularly, any violent exercise of respiration. In 
short, in the predisposed, any degree of external violence 
also may bring on the disease. 

836.] Occasioned by one or other of these causes (835.) 
the disease comes pn with a sense of weight and anxiety in 
the chest, some uneasiness in breathing, some pain of the 
breast or other parts of the thorax, and some sense of heat 
under the sternum ; and very often, before the disease ap- 
pears, a saltish taste is perceived in the mouth. 

837.] Immediately before the appearance of blood, a 
degree of irritation is felt at the top of the larynx. To re- 
lieve this, a hawking is made, which brings up a little blood, 
of a florid color, and somewhat frothy. The irritation re- 
turns ; and, in the same manner, more blood of a like 
kind is brought up, with some noise in the windpipe, as 
of air passing through a fluid. 

838.] This is commonly the manner in, which the he- 
moptysis begins ; but sometimes at the very first the blood 
comes up by coughing, or at least somewhat of coughing 
accompanies the hawking just now mentioned. 

839.] The blood issuing is sometimes at first in very 
small quantity, and soon disappears altogether : but, in 
other cases, especially when it repeatedly occurs, it is in 
greater quantity, and frequently continues to appear at 
times for several days together. It is sometimes profuse ; 
but rarely in such quantity as either by its excess, or by 
its sudden suffocation, to prove immediately mortal. It 
commonly either ceases spontaneously, or is stopped by 
the remedies employed. 

840.] When blood is thrown out from the mouth, it is 
not always easy to determine from what internal part it 
proceeds ; whether from the internal surface of the mouth 
itself, from the fauces, or adjoining cavities of the nose, 



266 PRACTICE OF PHYSIC. 

from the stomach, or from the lungs. It is, however, veri 
necessary to distinguish the different cases ; and, in most 
instances, it may be done by attending to the following 
considerations. 

841.] When the blood spit out, proceeds from some 
part of the internal surface of the mouth itself, it comes 
out without any hawking or coughing ; and generally, up- 
on inspection, the particular source of it becomes evident. 

842.] When blood proceeds from the fauces, or adjoin- 
ing cavities of the nose, it may be brought out by hawk- 
ing, and sometimes by coughing, in the manner we have 
described in 836, and 838 ; so that, in this way, a doubt 
may arise concerning its real source. A patient often lays 
hold of these circumstances to please himself with the 
opinion of its coming from the fauces, and he may be al- 
lowed to do so : but a physician cannot readily be deceiv- 
ed, if he consider, that a bleeding from the fauces is more 
rare than one from the lungs ; that the former seldom hap- 
pens but to persons who have been before liable either to an 
hemorrhagy of the nose, or to some evident cause of ero- 
sion ; and, in most cases, by looking into the fauces, the 
distillation of the blood, if it comes from thence, will be 
perceived. 

843.] When blood proceeds from the lungs, the manner 
in which it is brought up will commonly show from whence 
it comes : but, independent of that, there are many cir- 
cumstances which may occur to point it out, such as the 
period of life, the habit of body, and other marks of a 
predisposition (832. — 834.) and together with these, the 
occasional causes (835.) having been immediately before 
applied. 

844.] When vomiting accompanies the throwing out ot 
blood from the mouth, as vomiting and coughing often 
mutually excite each other ; so they may be frequently 
joined, and render it doubtful whether the blood thrown 
out proceeds from the lungs or from the stomach. We 
may however generally decide, by considering, that blood 
does not so frequently proceed from the stomach as from 
the lungs : that blood proceeding from the stomach com- 
monly appears in greater quantity, than when it proceeds 
from the lungs : that the blood proceeding from the lungs 
is usually of a florid color, and mixed with a little frothy 
mucus only ; whereas the blood from the stomach is com- 
monly of a darker color, more grumous, and mixed with 



PRACTICE OF PHYSIC. 267 

the other contents of the stomach : That the coughing or 
vomiting, according as the one or the other first arises in 
the cases in which they are afterwards joined, may some- 
times point out the source of the blood ; and, lastly, that 
much may be learned from the circumstances and symp- 
toms which have preceded the hemorrhagy. 

Those which precede the hemoptysis, enumerated in 
836, are most of them evident marks of an affection of 
the lungs. And, on the other hand, the hematemesis, or 
issuing of blood from the stomach, has also its peculiar 
symptoms and circumstances preceding it; as, for instance, 
some morbid affection of this organ, or at least some pain, 
anxiety, and sense of weight, referred distinctly to the re- 
gion of the stomach. To all this may be added, that the 
vomiting of blood happens more frequently to females 
than to males ; and to the former, in consequence of a sup- 
pression of their menstrual flux : and, by attending to all 
these considerations (841. — 844.) the presence of the he- 
moptysis may commonly be sufficiently ascertained. 



SECTION II. 

Of the Cure of Hemoptysis. 

845.] THIS disease is sometimes attended with little 
danger ; as when it happens to females in consequence of 
a suppression of the menses ;* when, without any marks of 
a predisposition, it arises from external violence ; or when, 
from whatever cause arising, it leaves behind it no cough, 
dyspnoea, or other affection of the lungs. Even in such 
cases, however, a danger may arise from too large a wound 
being made in the vessels of the lungs ; from a quantity of 
red blood being left to stagnate in the cavity of the bron- 
chia ; and particularly, from any determination of the 
blood being made into the vessels of the lungs, which, by 
renewing the hemorrhagy, may have dangerous conse- 
quences. In every instance therefore of hemoptysis, the. 
effusion is to be moderated by the several means mention- 
ed (791, to 794.) 

846.] These measures are especially necessary when the 
hemoptysis arises in consequence of predisposition ; and 

• Theauthoi i led, " And w'.cn no symptoms of phthuis bare preceded or ae- 

" companies die liem 



268 PRACTICE OF PHYSIC. 

in all cases where there is the appearance of a large effu- 
sion, or where the hemorrhagy frequently returns, the ef- 
fusion is not only to be moderated, but to be entirely stop- 
ped, and the returns of it prevented by every means in 
our power. See 796, and following.* 

847.] To stop an hemoptysis, or prevent the returns of 
it, two medicines have been frequently employed ; neither 
of which 1 can approve of. These are, chalybeates, and 
the Peruvian bark. As both of them contribute to increase 
the phlogistic diathesis of the system, they can hardly be 
safe in any case of active hemorrhagy, and I have fre- 
quently found them hurtful. 

848.] As the hemoptysis which happens in consequence 
of predisposition, is always attended with a phlogistic dia- 
thesis : and, as the bad consequences of the disease are es- 
pecially to be apprehended from the continuance of that 
diathesis ; so this is to be industriously taken off by blood- 
letting, in greater or smaller quantity, and more or Jess 
frequently repeated, according as the symptoms shall di- 
rect. At the same time, cooling purgatives are to be em- 
ployed, and every part of the antiphlogistic regimen is to 
be strictly enjoined. The refrigerants may also be adminis- 
tered ; taking care, however, that the acids, and more es- 
pecially the nitre, f do not excite coughing. 

* The tincture of roses has been frequently employed with success in these cases : alum, how- 
ever, is the principal astringent. It may be given, either by itself in small and often repeated 
doses, or combined with terra Japonica. The following formula is very convenient : 

R. Alumin. 

Terr. Japonic, 53. 3i« 

Conserv. Rosar. §i. 

M. f. Elect, cum. syr. commun. q. s. 

The dose ought to be proportioned to the exigency of the case : in general, the above pre- 
scribed mass mav be divided into ten equal parts ; one of which may be given every two hour*, 
or n urgent cases, every hour. In using (his medicine, it will be necessary to keep the belly 
oiien • but for this purpose, purgatives are ill adapted, as they carry oft with them the medi- 
cine that is employed : glysters are therefore preferable ; and in order that ihey be the more 
effectual, they ought to be somewhat of a stimulating nature : as, 

R. Infus. Sennae, Svi. 

Sal. Cathartic. Amar. si- 
Decoct. Hordei, SvLii. 
M. 

Or, . , .... 

R. Pulp. Tamarind. 511. 
Crem. Tart. !ft. 

Coque in Aq. font. q. s. ad colaturse Sxii. 
Adde, Mann. §ii. 
M. 

* Nitre ou»ht to be cautiously used in all complaints of the lungs, on account of the irntauo* 
wliieh ifrprorluces, and ^subsequent cough which it excites. 



PRACTICE OF PHYSIC. '269 

849.] From what was observed in 794, it will appear 
that blistering upon the breast or back may be a remedy of 
hemoptysis, when it is present ; and that issues in the same 
places may be useful in preventing the recurrence of it when 
it has ceased. 

850.] The avoiding of motion is generally a proper part 
of the antiphlogistic regimen ; and in the hemoptysis, no- 
thing is more necessary than avoiding bodily exercise : But 
some kinds of gestation, as sailing,* and travelling in an 
easy carriage on smooth roads, have often proved a remedy. 

851 .] Such is the treatment I can propose for the hemop- 
tysis, considered merely as an hemorrhagy : But when, 
in spite of all our precautions, it continues to recur, it is 
often followed by an ulceration of the lungs, and a phthi- 
sis pulmonalis. This, therefore, I must now proceed to 
consider ; but, as it arises also from other causes besides the 
hemoptysis, itnnustbe treated of with a more general view.f 



CHAPTER IV. 

OF THE PHTHISIS PULMONALIS, OR CON- 
SUMPTION OF THE LUNGS. 

SECTION I. 

Of the Phenomena and Causes of the Phthisis 
Pulmonalis. 

852.] r I ^HE Phthisis Pulmonalis I would define to be, 
-L an expectoration of pus, or purulent matter 
from the lungs, attended with a hectic fever. 

• A sea-voyage has often been prescribed for hemoptysis: it is nevertheless, a very dangerous 
practice, on account of the violent agitation produced by the sea-sickness in the action of vo- 
miting. The violence of the retchings in sea-sickness, especially after the contents of the stom- 
ach are thoroughly evacuated, has been known to cause hemoptysis, by a rupture of some consi- 
derable vessel. The hemorrhagy, indeed, hence proceeding, is not an active hemorrhagy; but, 
nevertheless, in a phlogistic diathesis, which predisposes loan active hemorrhagy, we ought al- 
ways to be cautious how we employ remedies, which, although they do not immediately increase 
the predisposing diathesis, produce the least irritation, or give any violent shock in their action. 

Speaking loud, singing, playing on wind instruments, and whatever requires any exertion of 
the lungs, ought to he carefully avoided. 

+ In the cure of the hemoptysis, the patient's diink ought to be of the acidulous kind, or of 
the acidulous and astringent kinds conjoined. The vitriolic acid is therefore the most eligible, 
but it ought to be well diluted. A pleasant drink may be composed of one part of the tincture 
of roses, and four of cold water: or the tincture of roses may be prescribed with five limes tire 
quantity of water that is ordered in the Pharmacccpia. The acid of tartar dissolved in twenty 
times its weight of water, and sweetened with a little syrup of roses, is also a suitable drink. 
A decoction either of ihe fresh fruit of quinces, sweetened with sugar, or an infusion of quince 
m iini.il.ide, is another excellent acid astringent. 

In addition to what has been said, it may be proper to observe, that opium is admissible only 
in v ry few cases of hemoptysis, viz. when the hemoptysis is the consequence of coughing. Thes» 
eases arc very difficultly distinguished. If the blood be thrown out into the lungs, a cough is 

2 M 



210 PRACTICE OF PHYSIC. 

As this is the principal species of phthisis, I shall fre- 
quently in this chapter employ the general term of phthisis, 
though strictly meaning the phthisis pulmonalis. 

853.] I have met with some instances of an expectora- 
tion ot purulent matter, continuing for many years, accom- 
panied with very few symptoms of hectic, and at least with- 
out any hectic exquisitely formed : But, in none of these 
instances, were the persons so entirely free from symptoms 
of hectic, as to form any exception to the general definition. 

854.] In every instance of an expectoration of pus, I 
presume there is an ulceration of the lungs. The late Mr. 
de Haen is the only author that I know of, who has advanced 
another opinion, and has supposed, that pus may be form- 
ed in the blood-vessels, and be from thence poured into the 
bronebiae. Admitting his fact, I have attempted an expla- 
nation of the appearance of pus without ulceration in 349 ; 
but, after all, I cannot help suspecting the accuracy of his 
observations ; must entirely reject his explanation of them ; 
must however allow, that we still want facts to support the 
explanation 1 have offered ; and doubt much if it will apply 
to any case of phthisis. For these reasons I still conclude, 
agreeably to the faith of all other dissections, and the opi- 
nions of all physicians, that the symptoms mentioned in 
our definition depend always upon an ulceration formed in 
the lungs. 

855.] It has sometimes happened, that a catarrh was at- 
tended with an expectoration of a matter so much resem- 
bling pus, that physicians have been often uncertain whe- 
ther it was mucus or pus, and therefore whether the dis- 
ease was a catarrh or a phthisis. It is often of consequence 
to determine these questions ; and it appears to me that it 
may be generally done, with sufficient certainty, from 
the following considerations, of which each particular is not 
always singly decisive, but when tbey are taken together, 
can hardly deceive us. 

1. From the color of the matter ; as mucus is naturally 
transparent, and pus always opaque. When mucus be- 
comes opaque, as it sometimes does, it becomes white, 
yellow, or greenish ; but the last mentioned color is hardly 
ever so remarkable in mucus as in pus. 

excited for its discharge, arul then the hemoptysis is the piimary disease: In this rase opiunr 
doc- in": ;ood. liui if a cough arising fromany other irritating cause, than extra- 

vased blood in the lun^s, should by its violence ami Long continuance, produce an hen 
then opium, joined with such remedies as are suitable 10 remove the peculiar irritation, is die 
only medicine on which we can ha\_- any reliance ; and in these cam we uiu-l u>e it in Urge 
doses, such as forty or fifty drops of laudaunm, 



PRACTICE OF PHVSIQ. 271 

2. From the consistence ; as mucus is more viscid and co- 
herent, and'pus less so, and may be said to be more friable. 
When mucus is thrown into water, it is not readily diffused, 
but remains united in uniform and circular masses: but pus, 
an the same circumstances, though not readily diffused, does 
not remain so uniformly united, and by a little agitation 
is broken into ragged fragments. 

3. From the odor ; which is seldom perceived in mucus, 
but frequently in pus. It has been proposed to try the odor 
of the matter expectorated, by throwing it upon live coals ; 
but in such a trial both mucus and pus give out a disagreea- 
ble smell, and it is not easy to distinguish between them. 

4. From the specific gravity compared with water ; and 
indeed, it is usual for the mucus of the lungs to swim on 

the surface of water, and for pus to sink in it. But in this 
we may sometimes be deceived ; as pus which has entangled 
a great deal of air may swim, and mucus that is free from 
air may sink. 

5. From the mixture which is discernible in the matter 
brought up : for if a yellow or greenish matter appears sur- 
rounded with a quantity of transparent or less opaque and 
less colored matter, the more strongly colored matter may 
be generally considered as pus ; as it is not easy to under- 
stand how one portion of the mucus of the lungs can be ve- 
ry considerably changed, while the rest of it is very little so, 
or remains in its ordinary state. 

6. From the admixture of certain substances with the 
matter thrown out from the lungs. To this purpose we are 
informed by the experiments of the late Mr. Charles Dar- 
win : a. That the vitriolic acid dissolves both mucus and 
pus, but most readily the former : That, if water be added 
to such a solution of mucus, this is separated, and either 
swims on the surface, or, divided into iiocculi, is suspend- 
ed in the liquor ; whereas, when water is added to a like so- 
lution of pus, this falls to the bottom, or by agitation is 
dilfujgd so as to exhibit an uniformly turpid liquor, b. That 
a solar ion of the caustic fixed alkali, after sometime, dis- 
solves mucus, and generallv pus ; and, if water be added 
to such solutions, the pus is precipitated, but the mucus is 
not. From such experiments it is supposed, that pus and 
mucus may be certainly distinguished from each other. 

7. From the expectoration's being attended with a hectic, 
fever. A catarrh, or expectoration of mucus, is often at- 
tended with fever ; but never, so far as I have observed, 



272 PRACTICE OF PHYSIC. 

with such a fever as I am present! v to describe as a hectic. 
Ihis, in my opinion, is the most*' certain mark of a puru- 
lent state m some part of the body ; and if others have 
thought differently, I am persuaded that it has been owing 
to this, that, presuming upon the mortal nature of a con- 
firmed or purulent phthisis, they have considered every 
casein which a recovery happened, as a catarrh only : but, 
that they may have been mistaken in this, shall be shewn 
hereafter. 

856.] Having thus considered the first part of the charac- 
ter of the phthisis pulmonalis as a mark of an ulceration of 
the lungs ; and having just now said, that the other part of 
the character, that is, the hectic fever, is a mark or indi- 
cation of the same thing ; it is proper now to consider this 
here, as I had with that view omitted it before (74.) 

857.] A hectic fever has the form of a remittent, which 
has exacerbations twice every day. The first of these oc- 
curs about noon, sometimes a little sooner or later ; and a 
slight remission of it happens about five, afternoon. This 
last is soon succeeded by another exacerbation, gradually 
increasing till after midnight : But after two o'clock of the 
morning, a remission takes place, which becomes more and 
more considerable as the morning advances. The exacer- 
bations are frequently attended with some degree of cold 
shivering ; or at least, the patient is exceedingly sensible 
to any coolness of the air, seeks external heat, and often 
complains of a sense of cold, when, to the thermometer, his 
fckin is preternaturally warm. Of these exacerbations, that 
of the evening is always the most considerable. 

858.] It has commonly been given as a part of the cha- 
racter of a hectic fever, that an exacerbation of it com- 
monly appears after the taking food; and it is true that 
dinner, which is taken at noon or after it, does seem to oc- 
casion some exacerbation. But this must not make us judge 
the mid-day exacerbation to be the effect of eating only ; for 
I have often observed it to come on an hour before noon, 
and often some hours before dinner; which, in this country 
at present, is not taken till some time afternoon. It is indeed 
to be observed, that in almost every person, the taking food 
occasions some degree of fever : but I am persuaded this 
would not appear so considerable in a hectic, were it not that 
an exacerbation of fever is present from another cause ; and 
accordingly, the taking food in the morning has hardly any 
sensible effect. 



PRACTICE OF PHYSIC. 273 

859.] I have thus described the general form of hectic 
fever ; but many circumstances attending it, are further to 
be taken notice of. 

The fever I have described does not commonly subsist 
long, till the evening exacerbations become attended with 
sweatings ; which continue to recur, and to prove more and 
more profuse, througli the whole course of the disease. 

Almost from the first appearance of the hectic, the urine 
is high-colored, and deposits a copious branny red sediment 
which hardly ever falls close to the bottom of the vessel. 

In the hectic, the appetite for food is generally less im- 
paired than in any other kind of fever. 

The thirst is seldom considerable ; the mouth is commonl v 
moist ; and as the disease advances, the tongue becomes 
free from all fur, appears very clean ; and in the advanced 
stages of the disease, the tongue and fauces appear to be 
sowewhat inflamed, and become more or less covered with 
aphtinr. 

As the disease advances, the red vessels of the adnata of 
the eye disappear, and the whole of the adnata becomes of 
a pearly white. 

The face is commonly pale; but, during the exacerba- 
tions, a florid red, and an almost circumscribed spot, appear 
on each cheek. 

For some time, in the course of a hectic, the belly is 
bound ; but, in the advanced stages of it, a diarrhoea almost 
always comes on, and continues to recur frequently during 
the rest of the disease, alternating in some measure with the 
sweatings mentioned above. 

The disease is always attended with a debility, which 
gradually increases during the course of it. 

During the same course, an emaciation takes place, and 
goes to a greater degree than in almost any other case. 

The falling off of the hairs, and the adunque form of the 
nails, are also symptoms of the want of nourishment. 

Towards the end of the disease, the feet are often affected 
with cedematous swellings. 

The exacerbations of the fever are seldom attended with 
any headach, and scarcely ever with delirium. 

The senses and judgment commonly remain entire to the 
very end of the disease ; and the mind, for the most part, 
is confident and full of hope. 

Some days before death, a delirium comes on. and com- 
monly continues to the end. 



274 PRACTICE OF PHYSIC. 

860.] The hectic fever now described (857,858.) as ac- 
companying a purulent state of the lungs, is perhaps the 
case in which it most frequently appears : but I have never 
seen it in any case, when there was not evidently, or when 
I had not ground to suppose, there was a permanent puru- 
lency or ulceration in some external or internal part. It 
was for this reason that in 74, I concluded it to be a sympto- 
matic fever only. Indeed, it appears to me to be always the 
effect of an acrimony absorbed from abscesses or ulcers, al- 
though it is not equally the effect of every sort of acrimony ; 
for the scorbutic and cancerous kinds often subsist long in 
the body without producing a hectic. What is the precise 
state of the acrimony producing this, I cannot determine, 
but it seems to be chiefly that of a vitiated purulency. 

861.] However this may be, it appears, that the hectic's 
depending in general upon an acrimony, explains its pecu- 
liar circumstances. The febrile state seems to be chiefly an 
exacerbation of that frequency of the pulse, which occurs 
twice every day to persons in health, and may be produced 
by acrimony alone. These exacerbations, indeed, do not 
happen without the proper circumstances of pyrexia ; but 
the spasm of the extreme vessels in a hectic does not seem 
to be so considerable as in other fevers ; and hence the state 
of sweat and urine which appears so early and so constantly 
in hectics. Upon the same supposition of an acrimony cor- 
rupting the fluids, and debilitating the moving powers, I 
think that most of the other symptoms may also be explained. 

862.] Having thus considered the characteristical symp- 
toms and chief part of the proximate cause of the phthisis 
pulmonalis, I proceed to observe, than an ulcer of the lungs, 
and its concomitant circumstances of hectic fever, may arise 
from different previous affections of the lungs ; all of which 
however may, in my opinion, be referred to five heads ; that 
is, 1. To an hemoptysis ; 2. To a suppuration of the lungs 
in consequence of pneumonia ; 3. To catarrh ; 4. To asth- 
ma; or, 5. To a tubercle. These several affections, as cau- 
ses of ulcers, shall now be considered in the order men- 
tioned. 

863.] It has been commonly supposed, that an hemop- 
tysis was naturally, and almost necessarily, followed by an 
ulcer of the lungs: but I will presume to say, that, in ge- 
neral, this is a mistake; for there have been many instances 
of hemoptysis occasioned by external violence, without 
being followed by any ulcer of the lungs; and there have 



PRACTICE OF PHYSIC. 275 

also been many instances of hemoptysis from an internal 
cause, without any consequent ulceration. And this too 
has been the case, not only when the hemoptysis happen- 
ed to young persons, and recurred for several times, but 
when it has often recurred during the course of a long life. 
It is indeed easy to conceive, that a rupture of the vessels 
of the Jungs like that of the vessels of the nose, may be 
often healed, as the surgeons speak, by the first intention. 
It is probable therefore, that it is an hemoptysis in parti- 
cular circumstances only, which is necessarily followed by 
an ulcer; but what these circumstances are, it is difficult to 
determine. It is possible, that merely the degree of rup- 
ture, or frequently repeated rupture preventing the wound 
from healing by the first intention, may occasion an ulcer ; 
or it is possible that red blood effused, and not brought up 
entirely by coughing, may, by stagnating in the bronchia?, 
become acrid, and erode the parts. These however are 
but suppositions, not supported by any clear evidence. 
And, if we consider that those cases of hemoptysis which 
follow the predisposition (831. — 834.) are those especially 
which end in phthisis, we shall be led to suspect that there 
are some other circumstances which concur here to deter- 
mine the consequence of hemoptysis, as 1 shall hereafter 
endeavor to show. 

864.] Any supposition, however, which we can make 
with respect to the innocence of an hemoptysis, must not 
supersede the measures* proposed above for its cure; both 
because we cannot certainly foresee what may be the conse- 
quence of such an accident, and because the measures 
above suggested are safe ; for, upon every supposition, it 
is a diathesis phlogistica that may urge on every bad con- 
sequence to be apprehended. 

865.] The second cause of an ulceration of the lungs, to 
be considered, is a suppuration formed in consequence of 
pneumonia. * 

866.] From the symptoms mentioned in 857, 858, 
it may with reason be concluded, that an abscess, or, as it 
is called, a vomica, is formed in some part of the pleura, 
and most frequently in that portion of it investing the lungs. 
Here purulent matter frequently remains for some time, 
as if enclosed in a cyst: but commonly it is not long be- 
fore it comes to be either absorbed, and transferred to 
some other part of the body ; or that it breaks through in- 
to the cavity of the lungs, or into that of the thorax. In 



276 PRACTICE OF PHYSIC. 

the latter case, it produces the disease called empyema) 
but it is only when the matter is poured into the cavitv of 
the branchiae, that it properly constitutes the phthisis pul- 
monalis. In the case of empyema, the chief circumstances 
of a phthisis are indeed also present; but I shall here consi- 
der that case only in which the abscess of the lungs gives 
occasion to a purulent expectoration. 

867.] An abscess of the lungs, in consequence of pneu- 
monia, is not always followed by a phthisis : for sometimes 
a hectic fever is not formed ; the matter poured into the 
bronchia? is a proper and benign pus, which is frequently 
coughed up very readily, and spit out ; and, though this 
purulent expectoration should continue for some time, yet 
if a hectic does not come on, the ulcer soon heals, and 
every morbid symptom disappears. This has happened 
so frequently, that we may conclude, that neither the ac- 
cess ot the air, nor the constant motion of the lungs, will 
prevent an ulcer of these parts from healing, if the mat- 
ter of it be well-conditioned. An abscess of the Jungs, 
therefore, does not necessarily produce the phHiisis puU 
monalis ; and if it be followed by such a disease, it must 
be in consequence of particular circumstances which cor- 
rupt the purulent matter produced, render it unsuitable to 
the healing of the ulcer, and at the same time make it af- 
ford an acrimony, which, being absorbed, produces a 
hectic and its consequences. 

868.] The corruption of the matter of such abscesses 
mav be owing to several causes, as, 1 . That the matter ef- 
fused during the inflammation, had not been a pure serum 
fit to be converted into a laudable pus, but had been united 
with other matters which prevented that, and gave a consi- 
derable acrimony to the whole : Or, 2. That the matter ef- 
fused, and converted into pus, either merely by a long 
stagnation in a vomica, or by its connection with an em- 
pyema, had been so corrupted, as to become unfit for the 
Eurpose of pus in the healing of the ulcer. These seem to 
e possible causes of the corruption (if matter in abscesses, 
so as to make it the occasion of phthisis in persons other- 
wise sound ; but it is probable, that a pneumonic absi 
does especially produce phthisis when it happens to persons 
previously disposed to that disease, and therefore only as it 
concurs with some other causes of it. 

869.] The third cause supposed to produce phthisis, is a 
catarrh ; which in many cases seems, in length of time, to 



PRACTICE OF PHYSIC. 277 

have the expectoration of mucus proper to it, gradually 
changed into an expectoration of pus ; and at the same time, 
by the addition of a hectic fever, the disease, which was at 
first a pure catarrh, is converted into a phthisis. This sup- 
position, however is not easily to be admitted. The catarrh 
is properly an affection of the mucous glands of the treachea 
and bronchiae, analogous to the coryza, and less violent 
kinds of cynanche tonsillaris, which very seldom terminate 
in suppuration. And although a catarrh should be disposed 
to such termination, yet the ulcer produced might readily 
heal up, as it does in the case of a cynanche tonsillaris ; and 
therefore should not produce a phthisis. 

870.] Further, the catarrh, as purely the effect of cold, 
is generally a mild disease, as well as of short duration ; 
and of the numerous instances of it, there are at most but 
very few cases which can be said to have ended in phthisis. 
In all those cases in which this seems to have happened, it 
is to me probable, that the persons affected were peculi- 
arly predisposed to phthisis. And the beginning of phthisis 
so often resembles a catarrh, that the former may have 
been mistaken for the latter. Besides, to increase the fal- 
lacy, it often happens that the application of cold, which 
is the most frequent cause of catarrh, is also frequently 
the exciting cause of the cough which proves the begin- 
ning of phthisis. 

871.] It is to me, therefore probable, that a catarrh 
is very seldom the foundation of phthisis; but 1 would not 
positively assert that it never is so; for it is possible that 
the cases of a more violent catarrh may have joined with 
them a pneumonic affection, which may end in a suppura- 
tion; or it may happen that a long continued catarrh, by 
the violent agitation of the lungs in coughing, will produce 
some of those tubercles which are presently to be mention- 
ed as the most frequent cause of phthisis. 

872.] It must be particularly observed here, that no- 
thing said in 871 should allow us to neglect any appear- 
ance of catarrh, as is too frequently done; for it may be 
either the beginning of a phthisis, which is mistaken for a 
genuine catarrh, or that even as a catarrh continuing long, 
it may produce a phthisis, as in 871. 

873.] Many physicians have supposed an acrimony of 
the fluids eroding some of the vessels of the lungs, to be a 
frequent cause of ulceration and phthisis. But this ap- 
pears to me to be a mere supposition ; for in any of the in- 

2n 



278 PRACTICE OF PHVSIC. 

stances of the production of phthisis which I have seen, 
there was no evidence of any acrimony of the blood capa- 
ble of eroding the vessels. It is true, indeed, that in ma- 
ny cases an acrimony subsisting in some part of the fluids, 
is thcecause of the disease ; but it is at the same time pro- 
bable, that this acrimony operates by producing tubercles, 
rather than bysany direct erosion. 

874.] It has been mentioned in 862, that an asthma 
may be considered as one of the causes of phthisis; and 
by asthma I mean, that species of it which has been com- 
monly named the Spasmodic. This disease frequently 
subsists very long without producing any other, and may 
have its own peculiar fatal termination, as shall be explain- 
ed hereafter. But I have seen it frequently end in phthisis ; 
and in such cases I suppose it to operate in the manner 
above ailed ged of catarrh, that is, by producing tuber- 
cles, and their consequences, which shall be presently 
mentioned. 

875.] I come now to consider the fifth head of the cause 
of phthisis, and which I apprehend to be the most frequent 
of any. This I have said, in general, to be tubercles ; by 
which terms are meant, certain small tumours, which have 
the appearance of indurated glands. Dissections have fre- 
quently shown such tubercles formed in the lungs ; and al- 
though at first indolent, yet at length they become inflam-. 
ed, and are thereby changed into little abscesses, or vomi- 
cae, which breaking, and pouring their matter into the 
bronchiae, give a purulent expectoration, and thus lay the 
foundation of phthisis. 

876.] Though the matter expectorated upon these occa- 
sions has the appearance of pus, it is seldom that of a lau- 
dable kind; and, as the ulcers do not readily heal, but are 
attended' with a hectic fever, for the most part ending fa- 
tally, I presume that the matter of the ulcers is imbued 
with a peculiarly noxious acrimony, which prevents 
their healing, and produces a phthisis in all its circum- 
stances, as mentioned above. 

877.] It is very probable that the acrimony which thus 
discovers itself in the ulcers, existed before, and produced 
the tubercles themselves: and it is to -this acrimony that 
we must trace up the cause of the phthisis following these 
tubercles. This acrimony is probably, in different cases, 
of different kinds ; and it will not be easy to determine its 
varieties: but to a certain length I shall attempt it. 



PRACTICE OF PHYSIC. 279 

878.] In one case, and that, too, a very frequent one, 
of phthisis, it appears, that the noxious acrimony is of the 
same kind with that which prevails in the scrophula. This 
may be concluded from observing, that a phthisis, at its 
usual periods, frequently attacks persons born of scrophu- 
lous parents; that is, of parents who had been affected with 
scrophula in their younger years : that very often, when the 
phthisis appears, there occurs at the same time some lym- 
phatic tumors in the internal parts; and very often I have 
found the tabes mesenterica, which is a scrophulous affec- 
tion, joined with the phthisis pulmonalis. To all this I 
would add, that, even when no scrophulous affection lias 
either manifestly preceded or accompanied a phthisis, this 
last however most commonly affects persons of a habit re- 
sembling the scrophulous ; that is, persons of a sanguine, 
or of a sanguineo-melancholic temperament, who have ve- 
ry fine skins, rosy complexions, large veins, soft flesh, and 
thick upper lip: and further, that in such persons the phthi- 
sis comes on in the same manner that it does in persons 
having tubercles, as shall be immediately explained. 

879.] Another species of acrimony producing tubercles 
of the lungs, and thereby phthisis, may be said to be the 
exanthematic. It is well known, that the small-pox some- 
times, and more frequently the measles, lay the foundation 
of phthisis. It is probable also, that other exanthemata have 
the same effect; and from the phenomena of the disease, 
and the dissections of persons who have died of it, it is 
probable, that all the exanthemata may occasion a phthi- 
sis, by affording a matter which in the first place produces 
tubercles. 

880.] Another acrimony, which seems sometimes to 
produce phthisis, is the siphylitic ; but whether such an 
acrimony produces phthisis in any other persons than the 
previously disposed, does not appear to me certain. 

881.] What other species of acrimony, such as from 
Scurvy, from pus absorbed from other parts of the body, 
from suppressed eruptions, or from other sources, may al- 
so produce tubercles and phthisis, I cannot now decide, 
but must leave to be determined by those who have had 
experience in such eases. 

882.] There is one peculiar case of phthisis, which from 
my own experience I can take notice of. This is the case 
of phthisis from a calcarious matter formed in the lungs, 
and coughed up, frequently with a little blood, sometimes 



280 PRACTICE OF PHYSIC. 

with mucus only, and sometimes with pus. How this mat- 
ter is generated, or in what precise part of the lungs it is 
seated, I acknowledge myself ignorant. In three cases of 
this kind which have occurred to me, there was at the same 
time no appearance of stony or earthy concretions in any 
other part of the body. In one of these cases, an exqui- 
sitely formed phthisis came on, and proved mortal : while 
in the other two, the symptoms of phthisis were never fully 
formed ; and after some time, merely by a milk diet and 
avoiding irritation, the patients entirely recovered. 

883.] Another foundation for phthisis, analogous, as I 
judge, to that of tubercles, is that which occurs to certain 
artilicers whose employments keeps them almost constantly 
exposed to dust ; such as stone-cutters, millers, flax-dressers, 
and some others. I have not observed in this country ma- 
ny instances of phthisis which could be referred to this 
cause; but, from Ram azzini, Morgagni, and some other 
writers, we must conclude such cases to be more frequent 
in the southern parts of Europe. 

884.] Besides these now mentioned, there are probably 
some other causes producing tubercles, which have not yet 
been ascertained by observation ; and it is likely, that in 
the state of tubercles there is a variety not yet accounted for ; 
but all this must be left to future observation and inquiry. 

885.] It has been frequently supposed by physicians, 
that the phthisis is a contagious disease ; and I dare not as- 
sert that it never is such : but in many hundred instances of 
the disease which I have seen, there has been hardly one 
which to me could appear to have arisen from contagion. 
It is possible, that in warmer climates the effects of conta- 
gion may be more discernible. 

After having said, that a phthisis arises from tubercles 
more frequently than from any other cause, and after hav- 
ing attempted to assign the variety of these, I now proceed 
to mention the peculiar circumstances and symptoms which 
usually accompany the coming on of the disease from tu- 
bercles. 

886.] A tuberculous and purulent state of the lungs has 
been observed in very young children, and in some others 
at several different periods before the age of puberty and 
full growth ; but instances of this kind are rare : and the 
attack of phthisis, which we have reason to impute to tu- 
bercles, usually happens at the same period which I have 
assigned for the coming on of the hemoptysis. 



PRACTICE OF PHYSIC. 281 

887.] The phthisis from tubercles does also generally af- 
fect the same habits as the hemoptysis, that is, person* of 
a slender make, long necks, narrow chests, and prominent 
shoulders ; but very frequently the persons liable to tuber- 
cles have less of a florid countenance, and of the other 
marks of an exquisitely sanguine temperament, than the 
persons liable to hemoptysis. 

888.] This disease, arising from tubercles, usually com- 
mences with a slight and short cough, which becomes 
habitual, is often little remarked by those affected, and 
sometimes so little as to be absolutely denied by them. At 
the same time their breathing becomes easily hurried by 
any bodily motion, their body grows leaner, and they be- 
come languid and indolent. This state sometimes continues 
for a year, or even for two years, without the persons 
making any complaint of it, excepting only that they are 
affected by cold more readily than usual, which frequently 
increases their cough, and produces some catarrh. This, 
again, however, is sometimes relieved ; is supposed to have 
arisen from cold alone : and therefore gives no alarm either 
to the patient or to his friends, nor leads them to take any 
precautions. 

889.] Upon one or other of thege occasions of catching 
cold, as we commonly speak, the cough becomes more con- 
siderable ; is particularly troublesome upon the patient's 
lying down at night ; and in this state continues longer than 
is usual in the case of a simple catarrh. This is more es- 
pecially to call for attention, if the increase and continuance 
of cough come on during the summer season. 

890.] The cough which comes on as in 888, is very often 
for a long time without any expectoration ; but when, from 
repeatedly catching cold, it becomes more constant, it is 
then at the same time attended with some expectoration, 
which is most considerable in the mornings. The matter 
of this expectoration becomes by degrees more copious, 
more viscid, and more opaque ; at length of a yellow or 
greenish color, and of a purulent appearance. The whole 
of the matter, however, is not always at once entirely 
changed in this manner ; but, while one part of it retains 
the usual form of mucus, another suffers the changes now 
described. 

891.] When the cough increases, and continues very fre- 
quent through the night, and when the matter expectorated 
undergoes the changes I have mentioned, the breathing at 



282 PRACTICE OF PHYSIC. 

the same time becomes more difficult, and the emaciation 
and weakness go on also increasing. In the female sex, as 
the disease advances, and sometimes early in its progress, 
the menses ceases to flow ; and this circumstance is to be 
considered as commonly the effect, although the sex them- 
selves are ready to believe it the sole cause of the disease. 

892.] When the cough comes on as in 888, the poise is 
often natural, and for sometime after continues to be so; 
but the symptoms have seldom subsisted long before the 
pulse becomes frequent, and sometimes to a considerable 
degree, without much of the other symptoms of fever. 
At length, however, evening exacerbations become remark- 
able ; and by degrees the fever assumes the exquisite form 
of hectic, as described in 857, 859. 

893.] It is seldom that the cough, expectoration, and fe- 
ver, go on increasing, in the manner now described, without 
some pain being felt in some part of the thorax. It is usu- 
ally and most frequently felt at first under the sternum, and 
that especially, or almost only, upon occasion of coughing ; 
but very often, and that too, early in the course of the dis- 
ease, a pain is felt on one side, sometimes very constantly, 
and so as to prevent the person from lying easily upon that 
side ; but at other times, the pain is felt only upon a full in- 
spiration, or upon coughing. Even when no pain is felt, it 
generally happens that phthisical persons cannot lie easily 
on some one of their sides, without having their difficulty 
of breathing increased, and their cough excited. 

894.] The phthisis begins, and sometimes proceeds to 
its fatal issue, in the manner described from 888, to 894, 
without any appearance of hemoptysis. Such cases are 
indeed rare ; but it is very common for the disease to ad- 
vance far, and even to an evident purulency and hectic state, 
without any appearance of blood in the spitting : so that it 
may be affirmea, the disease is frequently not founded in he- 
moptysis. At the same time, we must allow, not only that 
it sometimes begins with an hemoptysis, as is said in 863, 
but further, that it seldom happens that in the progress of 
the disease more or less of an hemoptysis does not appear. 
Some degree of blood-spitting does, indeed, appear some- 
times in the state mentioned (888, 892.) but more com- 
monly in the more advanced stages of the disease only, and 
particularly upon the first appearance of purulency. How- 
ever this may be, it is seldom, in the phthisis from tuber- 
cles, that the hemoptysis is considerable, or requires any re- 



PRACTICE OF PHYSIC. 283 

medies different from those which are otherwise necessary 
for the state of the tubercles. 

895. J I have now described a succession of symptoms 
which, in different cases, occupy more or less time. In 
this climate they very often take up some years, the symp- 
toms appearing especially in the winter and spring, com- 
monly becoming easier, and sometimes almost disappear- 
ing, during the summer : but returning again in winter, they 
at length after two or three years, prove fatal, towards the 
end of spring or the beginning of summer. 

896] In this disease, the prognosis is for the most part 
unfavorable. Of those affected with it, the greater number 
die ; but there are also many of them who recover entirely, 
after having been in very unpromising circumstances. What 
are, however, the circumstances more certainly determin- 
ing to a happy or to a fatal event, I have not yet been able 
to ascertain. 

897.] The following aphorisms are the result of my ob- 
servations. 

A phthisis pulmonalis from hemoptysis, is more fre- 
quently recovered than one from tubercles. 

An hemoptysis not only is not always followed by a phthi- 
sis, as we have said above (863.) but even when followed 
by an ulceration, the ulceration is sometimes attended 
with little of hectic, and frequently admits of being soon 
healed. Even when hemoptysis and ulceration have hap- 
pened to be repeated, there are instances of persons reco- 
vering entirely after several such repetitions. 

A phthisis from a suppuration in consequence of pneu- 
monic inflammation, is that which most rarely occurs in 
this climate ; and a phthisis does not always follow such 
suppuration, when the abscess formed soon breaks and dis- 
charges a laudable pus ; but, if the abscess continues long 
shut up, and till after a considerable degree of hectic has 
been formed, a phthisis is then produced, equally danger- 
ous, as that from other causes. 

A phthisis from tubercles has, I think, been recovered : 
but it is of all others the most dangerous ; and, when aris- 
ing from a hereditary taint is almost certainly fatal. 

The danger of a phthisis, from whatever cause it may 

have arisen, is most certainly to be judged of by the de- 

to which the hectic and its consequences have arrived. 

from a certain degree of emaciation, debility, profuse 

sweating, and diarrhoea, no person recovers. 



284 PRACTICE OF PHYSIC. 

A mania coming on, has been found to remove all the 
symptoms, and sometimes has entirely cured the disease; 
but, in other cases, upon the going off of the mania, the 
phthisis has recurred, and proved fatal. 

The pregnancy of women has often retarded the progress 
of a phthisis ; but commonly it is only tijl after delivery, 
when the symptoms of phthisis return with violence, and 
soon prove fatal. 



SECTION II. 
Of the Cure of Phthisis. 



898.] FROM what has been just now said, it will readily 
appear, that the cure of the phthisis pulmonalis must be 
exceedingly difficult ; and that even the utmost care and 
attention in the employment of remedies, have seldom suc- 
ceeded. It may be doubtful whether this failure is to be 
imputed to the imperfection of our art, or to the absolutely 
incurable nature of the disease. I am extremely averse in 
any case to admit of the latter supposition, and can always 
readily allow of the former ; but, in the mean time, must 
mention here, what has been .attempted towards either cur- 
ing or moderating the violence of this disease. 

899.] It must be obvious that according to the differ- 
ent circumstances of this disease, the method of cure must 
be different. Our first attention should be employed in 
watching the approach of the disease, and preventing its 
proceeding to an incurable state. 

In all persons of a phthisical habit, and especially in those 
born of phthisical parents, the slightest symptoms of the 
approach of phthisis, at the phthisical period of life, ought 
to be attended to.* 

900.] When an hemoptysis occurs, though it be not al- 
ways followed with ulceration and phthisis, these however 
are always to be apprehended ; and every precaution is to 
be taken against them. This is especially to be done by 
employing every means of moderating the hemorrhagy, and 
of preventing its return, directed in 891, et seq. and these 
precautions ought to be continued for several years after the 
occurrence of the hemoptysis. 

* This early attention to the first symptoms of the disease is of the utmost consequence, for It 
is ontv in the early stage that any remedies can be employed with success, as experience has 

sufficient;-.' taught. See article r <0:>. el seq. 



PRACTICE OF PHYSIC. 285 

901.] The phthisis which follows a suppuration from 
pneumonic inflammation, can only be prevented with cer- 
tainty, by obtaining a resolution of such inflammation. 
What may be attempted towards the cure of an abscess and 
ulcer which have taken place, I shall speak of hereafter. 

902.] I have said, it is doubtful if a genuine catarrh ever 
produces a phthisis ; but have allowed that it possibly may : 
and both upon this account, and upon account of the 
ambiguity which may arise, whether the appearing catarrh 
be a primary disease, or the effect of a tubercle, I consider 
it as of consequence to cure a catarrh as soon as possible 
after its first appearance. More especially when it shall 
linger, and continue for some time, or shall, after some 
intermission, frequently return, the cure of it should be 
diligently attempted. The measures requisite for this 
purpose shall be mentioned afterwards, when we come to 
treat of catarrh as a primary disease ; but, in the mean 
time, the means necessary for preventing its producing a 
phthisis shall be mentioned immediately, as they are the 
same with those I shall point out as necessary for prevent- 
ing a phthisis from tubercles. 

903.] The preventing of a phthisis from asthma must 
be by curing, if possible, the asthma, or at least by mode- 
rating it as much as may be done: and as it is probable that 
asthma occasions phthisis, by producing tubercles, the mea- 
sures necessary for preventing phthisis from asthma, will 
be the same with those necessary in the case of tubercles, 
which I am now about to mention. 

904. J I consider tubercles as by much the most frequent 
cause of phthisis ; and even in many cases where this seems 
to depend upon hemoptysis, catarrh, or asthma, it does 
however truly arise from tubercles. It is upon this sub- 
ject, therefore, that I shall have occasion to treat of the 
measures most commonly requisite for curing phthisis. 

905.] When, in a person born of phthisical parents, of 
a phthisical habit, at the phthisical period of life, the symp- 
toms (888.) in the spring, or the beginning of summer, 
shall appear in the slightest degree, we may presume that 
a tubercle, or tubercles, either have been formed, or are 
forming in the lungs ; and therefore, that every means we 
can devise for preventing their formation, or for procuring 
their resolution, should be employed immediately, even 
although the patient himself should overlook or neglect the 
symptoms, as imputin g them to accidental cold. 

2o 



286 PRACTICE OF PHYSIC. 

906.] This is certainly the general indication ; but how 
it may be executed, I cannot readily say. I do not know 
that, at any time, physicians have proposed any remedy 
capable of preventing the formation of tubercles, or of 
resolving them when formed. The analogy of scrophula, 
gives no assistance in this matter. In scrophula the reme- 
dies that are seemingly of most power, are, sea-water, or 
certain mineral waters ; but these have generally proved 
hurtful in the case of tubercles of the lungs. I have known 
several instances of mercury very fully employed for cer- 
tain diseases, in persons who were supposed at the time to 
have tubercles formed, or forming, in their lungs ; but 
though the mercury proved a cure for those other diseases, 
it was of no service in preventing phthisis, and in some 
cases seemed to hurry it on. 

907.] Such appears to me to be the present state of our 
art, with respect to the cure of tubercles ; but I do not des- 
pair of a remedy for the purpose being found hereafter. In 
the mean time, all that at present seems to be within the 
reach of our art, is to take the measures proper for avoid- 
ing the inflammation of tubercles. It is probable that tu- 
bercles may subsist long without producing any disorder ; 
and I am disposed to think, that nature sometimes resolves 
and discusses tubercles which have been formed ; but that 
nature does this only when the tubercles remain in an un- 
inflamed state ; and therefore, that the measures necessary 
to be taken, are chiefly those for avoiding the inflammation 
of the tubercles. 

908.] The inflammation of a tubercle of the lungs is to 
be avoided upon the general plan of avoiding inflammation, 
by blood-letting, and by an antiphlogistic regimen ; the 
chief part of which, in this case, is the use of a low diet. 
This supposes a total abstinence from animal food, and the 
using of vegetable food almost alone : but it has been found, 
that it is not necessary for the patient to be confined to ve- 
getables of the weakest nourishment, it being sufficient that 
the farinacea be employed, and together with these, milk. 

909.] Milk has been generally considered as the chief 
remedy in phthisis, and in the case of every tendency to 
it ; but whether from its peculiar qualities, or from its 
being of a lower quality, with respect to nourishment, than 
any food entirely animal, is not certainly determined. The 
choice and administration of milk will be properly directed, 
by considering the nature of the milk of the several ani- 



PRACTICE OF PHYSIC. 281 

mals from which it may be taken, and the particular state 
of the patient with respect to the period and circumstances 
of the disease, and to the habits of his stomach with respect 
to milk. l 

910.] A second means of preventing the inflammation 
ot the tubercles of the Jungs, is, by avoiding any particu- 
lar irritation of the affected part, which may arise from any 
violent exercise of respiration ; from any considerable de- 
gree of bodily exercise ; from any position of the body, 
■which straitens the capacity of the thorax ; and lastly, from 
cold applied to the surface of the body, which determines 
the blood in greater quantity to the internal parts, and par- 
ticularly to the lungs. 

911.] From the last-mentioned consideration, the ap- 
plication of cold in general, and therefore the winter-sea- 
son, in cold climates, as diminishing the cutaneous perspi- 
ration, is to be avoided ; but more particularly, that appli- 
cation of cold is to be shunned that may suppress perspira- 
tion, to the degree of occasioning a catarrh, which consists 
in an inflammatory determination to the lungs, and may 
therefore most certainly produce an inflammation of the 
tubercles there. 

By considering, that the avoiding heat is a part of the 
antiphlogistic regimen above recommended, and by com- 
paring this with what has been just now said respecting 
the avoiding coid, the proper choice of climates and sea- 
sons for phthisical patients will be readily understood. 

912.] A third means of avoiding the inflammation of 
the tubercles of the lungs consists, in diminishing the de- 
termination of the blood to the lungs, by supporting and 
increasing the determination to the surface of the body ; 
which is to be chiefly and most safely done by warm clothl 
ing,* and the frequent use of the exercises of gestation. 

913.] Every mode of gestation has been found of use 
in phthisical cases ; but riding on horseback, as being 
accompanied with a great deal of bodily exercise, is less 
safe in persons liable to an hemoptysis. Travelling in a 
carriage unless upon very smooth' roads may also be of 
doubtful effect ; and all the modes of gestation that are 
employed on land, may fall short of the effects expected 

co'Tdimatcs. 11108 ' essential part in the cure of Phthisis, and many other diseases prevalent in 
The warm clothing that ii most effectual is flannel shim next to the skin It feels a little dis- 
a^ro-able at first to., person unaccustomed to n ; but the great relief il affords, and the com- 
fortable sensation ttproduces, are so strong inducement* for continuing its use, that few peo 
fie who hare once experienced iU beneficial effects have an; desire to relinquish it. ^ 



288 PRACTICE OF PHYSIC. 

from them, because they cannot be rendered sufficiently 
constant ; and therefore it is that sailing, of all other modes 
of gestation, is the most effectual in pneumonic cases, as 
being both the smoothest and most constant. 

It has been imagined, that some benefit is derived from 
the state of the atmosphere upon the sea ; but I cannot 
find that any impregnation of this which can be supposed 
to take place, can be of sendee to phthisical persons. It is 
however probable, that frequently some benefit may be 
derived from the more moderate temperature and greater 
purity of the air upon the sea. 

914.] In order to take off any inflammatory determina- 
tion of the blood into the vessels of the lungs, blisters ap- 
plied to some part of the thorax may often be of service ; 
and for the same purpose, as well as for moderating the 
general inflammatory state of the body, issues of various 
kinds may be employed with advantage. 

915.] The several measures to be pursued in the case of 
what is properly called an Incipient Phthisis, have now 
been mentioned ; but they have seldom been employed in 
such cases in due time, and have therefore, perhaps, sel- 
dom proved effectual. It has more commonly happened, 
that after some time, an inflammation has come upon the 
tubercles, and an abscess has been formed, which opening 
into the cavity of the bronchiae, has produced an ulcer, 
and a confirmed phthisis. 

916.] In this state of matters, some new indications dif- 
ferent from the former may be supposed to arise, and indi- 
cations for preventing absorption, for preventing the effects 
of the absorbed matter upon the blood, and for healing the 
ulcer, have been actually proposed. I cannot find, how- 
ever, that any of the means proposed for executing these 
indications, are either probable or have proved effectual. 
If, upon some occasions, they have appeared to be useful, 
it has been probably by answering some other intention. 

While no antidote against the poison which especially 
operates here, seems to have been as yet found out, it ap- 
pears to me, that too great a degree of inflammation has a 
great share in preventing the healing of the ulcer which 
occurs ; and such inflammation is certainly what has a 
great share in urging on its fatal consequences. The only 
practice, therefore, which I can venture to propose, is the 
same in the ulcerated as in the crude state of a tubercle ; 



PRACTICE OF PHYSIC. 289 

that is, the employment of means for moderating inflam- 
mation, which have been already mentioned (908. et seq.J 

917.] The balsamics whether natural or artificial, winch 
have been so commonly advised in cases of phthisis, ap- 
pear to me to have been proposed upon no sufficient 
grounds, and to have proved commonly hurtful. The re- 
sinous and acrid substance of myrrh, lately recommended, 
has not appeared to me to be of any service, and in some 
cases to have proved hurtful.* 

918.] Mercury, so often useful in healing ulcers, has 
been speciously enough proposed in this disease; but whe- 
ther that it be not adapted to the particular nature of the 
ulcers of the lungs occurring in phthisis, or that it proved 
hurtful because it cannot have effect without exciting such 
an inflammatory state of the whole system, as, in a hec- 
tic state, must prove very hurtful, I cannot determine. 
Upon many trials which I have seen made, it has proved of 
no service, and commonly has appeared to be manifestly 
pernicious. 

919.] The Peruvian bark has been recommended for se- 
veral purposes in phthisical cases; and it is said, upon some 
occasions to have been useful; but I have seldom found it 
to be so; and as by its tonic power it increases the phlo- 
gistic diathesis of the system, I have frequently found it 
hurtful. In some cases, where the morning remissions of 
the fever were considerable, and the noon exacerbations 
well marked, I have observed the Peruvian bark given in 
large quantities, have the effect of stopping these exacer- 
bations, and at the same time of relieving the whole of the 
phthisical symptoms : but in the cases in which I observed 
this, the fever showed a constant tendency to recur; and 
at length the phthisical symptoms also returned, and prov- 
ed quickly fatal. 

920.] Acids of all kinds, as antiseptic and refrigerant, 
are useful in cases of phthisis ; but the native acid of vege- 
tablesf is more useful than the fossil acids, as it can be gi- 
ven in much larger quantities, and may also be given more 
safely than vinegar, being less liable to excite coughing. 

921.] Though our art can do so little towards the cure 
of this disease, we must, however, palliate the uneas)^ 
symptoms of it as well as we can. The symptoms especial- 

• From the preceding account of the disease, it is sufficiently evident thai all a crid and hot 
substances must be hurtful in phthisis. The balsamics have been long recommended in these 
cases, en.n by the best authorities, but on w'jat principle is net easy lo determine. 

+ The aud fruits, acid of tartar, acid of sorrel, and nther plants yielding an acid, but not an 
acud, juice. The eating of oranges is therefore serviceable. 



290 PRACTICE OF PHYSIC. 

ly urgent are the cough and diarrhoea. The cough may be 
in some measure relieved by demulcents, (872.) but the 
relief obtained by these is imperfect and transitory, and 
very often the stomach is disturbed by the quantity of 
oily, mucilaginous, and sweet substances, which are on 
these occasions taken into it. 

922.] The only certain means of relieving the cough, is 
by employing opiates. These, indeed, certainly increase 
the phlogistic diathesis of the system; but commonly they 
do not so much harm in this way, as they do service by 
quieting the cough, and giving sleep. They are supposed 
to be hurtful by checking expectoration : but they do it 
for a short time only; and, after a sound sleep, the expec- 
toration in the morning is more easy than usual. In the 
advanced state of the disease, opiates seem to increase the 
sweatings that occur; but they compensate this, by the 
ease they afford in a disease which cannot be cured. 

923.] The diarrhoea which happens in the advanced state 
of this disease, is to be palliated by moderate astringents, 
mucilages, and opiates. 

Rhubarb, so commonly prescribed in every diarrhoea, 
and all other purgatives, are extremely dangerous in the 
colliquative diarrhoea of hectics. 

Fresh subacid fruits, supposed to be always laxative, 
are often in the diarrhoea of hectics, by their antiseptic 
quality, very useful. 



CHAPTER V. 

OF THE HEMORRHOIS ; OR OF THE HEMOR- 
RHOIDAL SWELLING AND FLUX. 

SECTION I. 

Of the Phenomena and Causes of the Hemorrhois. 

924.] A DISCHARGE of blood from small tumors 
jLX on the verge of the anus, is the symptom 
which generally constitutes the Hemorrhois ; or, as it is 
vulgarly called, the Hemorrhoidal Flux. But a discharge 
of blood from within the anus, when the blood is of a flo- 
rid color, showing it to have come from no great distance, 
is also considered as the same disease ; and physicians have 



PRACTICE OF PHYSIC. 291 

agreed in making two cases or varieties of it, under the 
names of External and Internal Hemorrhois. 

925.] In both cases it is supposed that the flow of blood 
is from tumors previously formed, which are named He- 
morrhoids, or piles ; and it frequently happens, that the 
tumors exist without any discharge of blood; in which 
case, however, they are supposed to be a part of the same 
disease, and are named Hemorrhoides Csecse, or Blind 
Piles. 

926.] These tumors, as they appear without the anus, 
are sometimes separate, round, and prominent, on the 
verge of the anus; but frequently the tumor is only one 
tumid ring, forming, as it were, the anus pushed without 
the body. 

927.] These tumors, and the discharge of blood from 
them, sometimes come on as an affection purely topical, and 
without any previous disorder in other parts of the body : 
but it frequently happens, even before the tumors are form- 
ed, and more especially before the blood flows, that vari- 
ous disorders are felt in different parts of the body, as head- 
ach, vertigo, stupor, difficulty of breathing, sickness, colic- 
pains, pain of the back and loins ; and often, together with 
more or fewer of these symptoms, there occurs a consider- 
able degree of pyrexia. 

The coming on of the disease with these symptoms, is 
usually attended with a sense of fullness, heat, itching, and 
pain in and about the anus. 

Sometimes the disease is preceded by a discharge of se- 
rous matter from the anus : and sometimes this serous dis- 
charge, accompanied with some swelling, seems to be in 
place of the discharge of blood, and to relieve those disor- 
ders of the system which we have mentioned. This serous 
discharge, therefore, has been named the Hemorrhois Alba. 

928.] In the hemorrhois, the quantity of blood discharg- 
ed is different upon different occasions. Sometimes the 
blood Hows only upon the persons going to stool ; and com- 
monly, in larger or lesser quantity, follows the discharge of 
the fasces. In other cases, the blood flows without any dis- 
charge of faeces ; and then, generally, it is after having been 
preceded by the disorders above mentioned, when it is also 
commonly in larger quantity. This discharge of blood is 
often very considerable ; and, by the repetition, it is often 
so great, as we could hardly suppose the body to bear but 
with the hazard of life. Indeed, though rarely, it has been 



292 PRACTICE OF PHYSIC. 

so great as to prove suddenly fatal. These considerable dis- 
charges occur especially to persons who have been frequent- 
ly liable to the disease. They often induce great debility ; 
and frequently a leucophlegmatia, or dropsy, which proves 
fatal. 

The tumors and discharges of blood in this disease, often 
recur at exactly stated periods. 

929.] It often happens, in the decline of life, that the 
hemorrhoidal flux, formerly frequent, ceases to flow ; and, 
upon that event, it generally happens that the persons are 
affected with apoplexy or palsy. 

930.] Sometimes hemorrhoidal tumors are affected with 
considerable inflammation ; which, ending in suppuration, 
gives occasion to the formation of fistulous ulcers in those 
parts. 

931.] The hemorrhoidal tumors have been often consi- 
dered as varicous tumors, or dilatations of veins ; and it is 
true, that in some cases varicous dilatations have appeared 
upon dissection. These, however, do not always appear; 
and I presume it is not the ordinary case, but that the tu- 
mors are formed by an effusion of blood into the cellular 
texture of the intestine near to its extremity. These tu- 
mors, especially when recently formed, frequently contain 
fluid blood ; but, after they have remained for some time, 
they are commonly of a firmer substance. 

932.] From a consideration of their causes, to be here- 
after mentioned, it is sufficiently probable, that hemorrhoi- 
dal tumors are produced by some interruption of the free 
return of blood from the veins of the lower extremity of 
the rectum ; and it is possible, that a considerable accumu- 
lation of blood in these veins, may occasion a rupture of 
their extremities, and thus produce the hemorrhagy or tu- 
mors I have mentioned. But, considering that the hemor- 
rhagy occurring here is often preceded by pain, inflamma- 
tion, and a febrile state, as well as by many other symptoms 
which show a connection between the topical affection and 
the state of the whole system, it seems probable that the 
interruption of the venous blood, which we have supposed 
to take place, operates in the manner explained in 768, and 
therefore, that the discharge of blood here is commonly from 
arteries. 

933.] Some physicians have been of opinion, that a dif- 
ference in the nature of the hemorrhois, and of its effects 
upon the system, might arise from the difference of the he- 



PRACTICE OF PHYSIC. 293 

morrhoidal vessels from which the blood issued. But it ap- 
pears to rne, that hardly in any case we can distinguish the 
vessels from which the blood flows ; and that the frequent 
inosculations, of both the arteries and veins which belong 
to the lower extremity of the rectum will render the effects 
of the hemorrhage nearly the same, from whichsoever of 
these vessels the blood proceed. 

934.] In 768, I have endeavored to explain the manner 
in which a certain state of the sanguiferous system might 
give occasion to an hemorrhoidal flux ; and I have no doubt, 
that this flux may be produced in that manner. I cannot, 
however, by any means admit that the disease is so often 
produced in that manner, or that, on its first appearance, 
it is so frequently a systematic affection, as the Stahlians 
have imagined, and. would have us to believe. It occurs in 
many persons before the period of life at which the venous 
plethora takes place ; it happens to females, in whom a ve- 
nous plethora, determined to the hemorrhoidal vessels, can- 
not be supposed ; and it happens to both sexes, and to per- 
sons of all ages, from causes which do not affect the sytem, 
and are manifestly suited to produce a topical affection only. 

935.] These causes of a topical affection are, in the first 
place, the frequent voiding of hard and bulky feces, which, 
not only by their long stagnation in the rectum, but espe- 
cially when voided, must press upon the veins of the anus, 
and interrupt the course of the blood in them. It is for this 
reason that the disease happens so often to persons of a slow 
and bound belly. 

936.] From the causes just now mentioned, the disease 
happens especially to persons liable to some degree of a pro- 
lapsus ani. Almost every person in voiding faeces has the 
internal coat of the rectum more or less protruded with- 
out the body ; and this will be to a greater or lesser degree, 
according as the hardness and bulk of the feces occasion a 
greater or lesser effort or pressure upon the anus. While 
the gut is thus pushed out, it often happens that the sphinct- 
er ani is contracted before the gut is replaced ; and, in con- 
sequence thereof, a strong constriction is made, which pre- 
venting the fallen-out gut from being replaced ; and at the 
same time preventing the return of blood from it, occasions 
its being considerably swelled, and its forming a tumid ring 
round the anus. 

937.] Upon the sphincter's being a little relaxed, as it is 
immediately after its strong contraction, the fallen-out por- 

8 H 



&H PRACTICE OF PHYSIC. 

tion of the gut is commonly again taken within the body ; 
but by the frequent repetition of such an accident, the size 
and fullness of the ring formed by the fallen- out gut, is 
much increased. It is therefore more slowly and difficultly 
replaced; and in this consists the chief uneasiness of hemor- 
rhoidal persons. 

938.] As the internal edge of the ring mentioned, is ne- 
cessarily divided by clefts, the whole often assumes the ap- 
pearance of a number of distinct swellings ; and it also fre- 
quently happens, that some portions of it, more considera- 
bly swelled than others, become more protuberant, and 
form those small tumors more strictly called Hemorrhoids,- 
or Piles. 

939.] From considering that the pressure of faeces, and 
other causes interrupting the return of venous blood from 
the lower extremity of the rectum, may operate a good 
deal higher up in the gut than that extremity, it may be 
easily understood that tumors may be formed within the 
anus ; and probably it also happens, that some of the tu- 
mors formed without the anus, as in 938, may continue 
when taken within the body, and even be increased by the 
causes just now mentioned. It is thus that I would explain 
the production of internal piles, which, on account of their 
situation and bulk, are not protruded on the person's going 
to stool, and are often, therefore, more painful. The same 
internal piles are more especially painful, when affected by 
the hemorrhagic effort described in 744, and 768. 

940.] The production of piles is particularly illustrated 
by this, that pregnant women are frequently affected with 
them. This is to be accounted for, partly from the pressure 
of the uterus upon the rectum, and partly from the costive 
habit to which pregnant women are usually liable. I have 
known many instances of piles occurring for the first time 
during the state of pregnancy ; and there are few women 
that have borne children who are afterwards entirely free 
from piles. The Stahlians have commonly asserted, that 
the male sex is more frequently affected with this disease 
than the female ; but in this country I have constantly found 
it otherwise. 

941.] It is commonly supposed, that the frequent use of 
purgatives, especially of those of the more acrid kind, and 
more particularly of aloetics, is apt to produce the liemoi 
rboidal affection ; and as these purgatives stimulate chiefly 



PRACTICE OF PHYSIC. 295 

the great guts, it seems sufficiently probable that they may 
excite this disease. 

942.] I have now mentioned several causes which may 
produce the hemorrhoidal tumors and flux as a topical af- 
fection only ; but must observe farther, that although the 
disease appears first as a purely topical affection, it may, by 
frequent repetition, become habitual ; and therefore may 
become connected with the whole system, in the manner 
already explained, with respect to hemorrhagy in general, 
in 747. 

943.] The doctrine now referred to will, it is apprehend- 
ed, apply very fully to the case of the hemorrhoidal flux ; 
and will the more readily apply, from the person who has 
been once affected being much exposed to a renewal of the 
causes which first occasioned the disease ; and from many 
persons being much exposed to a congestion in the hemor- 
rhoidal vessels, in consequence of their being often in an 
erect position of the body, and in an exercise which pushes 
the blood into the depending vessels, while at the same 
time, the effects of these circumstances are much favored 
by the abundance and laxity of the cellular texture about 
the rectum. 

944.] It is thus that the hemorrhoidal flux is so often ar- 
tificially rendered an habitual arid systematic affection ; and 
I am persuaded, that it is this which has given occasion to 
theStahlians toconsider the disease as almost universally such. 

945.] It is to be particularly observed here, that when 
the hemorrhoidal disease has either been originally, or has 
become in the manner just now explained, a systematic 
affection, it then acquires a particular connection with the 
stomach, so that certain affections there excite the hemor- 
rhoidal disease, and certain states of the hemorrhoidal af- 
fection excite disorders of the stomach. 

It is perhaps owing to this connection, that the gout 
sometimes affects the rectum. See 524. 



SECTION II. 

Of the Cure of Hemorrhoidal Affections. 

946.] ALMOST at all times it has been an opinion 
amongst physicians, and from them spread amongst the 
people, that the hemorrhoidal flux is a salutary evacuation, 
•winch prevents many diseases that would otherwise have 



296 PRACTICE OF PHYSIC. 

happened; and that it even contributes to give long life. 
This opinion, in later times, has been especially maintain- 
ed by Dr. Stahl, and his followers; and has had a great 
deal of influence upon the practice of physic in Germany. 

947.] The question arises with respect to hemorrhagv in 
general, and indeed it has been extended so far by the. 
Stahlians. I have accordingly considered it as a general 
question (766 — 779.) but it has been more especially agi- 
tated with regard to the disease now under considera- 
tion : And as to this, although 1 am clearly of opinion that: 
the hemorrhois may take place in consequence of the ge- 
neral state of the system (768.) or, what is still more fre- 
quent, that by repetition it may become connected with 
that general state (942.) and in either case cannot be sup- 
pressed without great caution ; I must beg leave, notwith- 
standing this, to maintain, that the first is a rare case; that 
generally the disease first appears as an affection purely to- 
pical, (934 — 941.) and that the allowing it to become habi- 
tual is never proper. It is a nasty disagreeable disease, 
ready to go to excess, and to be thereby very hurtful, as 
well as sometimes fatal. At best it is liable to accidents, 
and thereby to unhappy consequences. I am therefore of 
opinion, that not only the first approaches of the disease 
are to be guarded against, but even that, when it has taken 
place for some time, from whatever cause it may have pro- 
ceeded, the flux is always to be moderated, and the ne- 
cessity of it, if possible, superseded. 

948.] Having delivered these general rules, I proceed 
to mention more particularly, how the disease is to be 
treated, according to the different circumstances under 
which it may appear. 

When we can manifestly discern the first appearance of 
the disease to arise from causes acting upon the part only, 
the strictest attention should be employed in guarding 
against the renewal of these causes. 

949.] One of the most frequent of the remote causes of 
the hemorrhoidal affection, is a slow and bound belly (935.) 
and this is to be constantly obviated by a proper diet,* 
which each individual's own experience must direct ; or, 
if the management of diet be not effectual, the belly must 
be kept regular by such medicines as may prove gently 
laxative, without irritating the rectum. f In most cases it 

* Broths of all kind are proper in these cases : barley broth is preferable to that which is made 
with rice. Barley gruel, with pruens, is an excellent laxative broth. 
+ The lenitive electuary alone may in many cases be sufficient, when given in the quantity of 



PRACTICE OF PHYSIC. 297 

Will be of advantage to acquire a habit with respect to time, 
and to observe it exactly. 

950.] Another cause of hemorrhois to be especially at- 
tended to, is the prolapsus or protrusion of the anus, winch 
is apt to happen on a person's having a stool, (936.) If it 
shall occur to any considerable degree, and at the same 
time be not easily and immediately replaced, it most cer- 
tainly produces piles, or increases them when otherwise pro- 
duced. Persons therefore liable to this prolapsus, should, 
upon their having been at stool, take great pains to have 
the gut immediately replaced, by lying down in a hori- 
zontal posture, and pressing gently upon the anus, till the 
reduction shall be completely obtained. 

951.] When the prolapsus of which I speak, is occa- 
sioned only by voiding hard and bulky faeces, it should be 
obviated by the means mentioned in 949, and may be 
thereby avoided. But in some persons it is owing to a lax- 
ity of the rectum ; in which case it is often most consider- 
able upon occasion of a loose stool ; and then the disease 
is to be treated by astringents,* as well as by proper arti- 
fices for preventing the falling down of the gut. 

952.] These are the means to be employed upon the first 
approaches of the hemorrhoidal affection ; and when from 
neglect it shall have frequently recurred, and has become 
in some measure established, they are no less proper. In 
the latter case, however, some other means are also neces- 
sary. It is particularly proper to guard against a plethoric 
state of the body ; consequently, to avoid a sedentary life, 
a full diet, and particularly intemperance in the use of strong 
liquor ; which, as I should have observed before, is, in all 
cases of hemorrhagy, of the greatest influence in increasing 
the disposition to the disease. 

953.] I need hardly repeat here, that exercise of all kinds 
must be a chief means of obviating and removing a pletho- 
ric state of the body ; but upon occasion of the hemorrhoi- 
dal flux immediately approaching, both walking and riding, 
as increasing the determination of the blood into the hemor- 

hatf an ounce or six drachms. The following formula may be used where greater costivensnr 
prevalli i 

R. Sal. Nitri, 3ii. 
Pulv. Jalap. 3i. 
Elect. Lenitivi, §i. 
M. f. Elect, cujus sumat q. n. m. pro re nata. 

» Astringents may be used both internally and externally. The internal astringents are Alun:. 
Kino, I , .Vc. But in cases of hemorrhoids from la\ity, nothing produces a better 

effect that the frequent application of pledgets dipped in a strong mfusion of galls, or oak batk. 



293 PRACTICE OF PHYSIC. 

rhoidal vessels, are to be avoided. At other times, when no 
such determination has been already formed, those modei 
of exercise may be very properly employed.* 

954.] Cold bathing is another remedy that may be em- 
ployed to obviate plethora, and prevent hemorrhagy ; but 
it is to be used with caution. When the hemorrhoidal flux 
is approaching - , it may be dangerous to turn it suddenly 
aside by cold bathing : but during the intervals of the dis- 
ease, this remedy may be employed with advantage ; and 
in persons liable to a prolapsus ani, the frequent washing of 
the anus with cold water may be very useful. 

955.] These are the means for preventing the recurrence 
of the hemorrhoidal flux; and in all cases, when it'is not 
immediately approaching, they are to be emploved. When 
it has actually come on, means are to be employed for mo- 
derating it at much as possible, by the person's lying in a 
horizontal position upon a hard bed ; by avoiding exercise 
in an erect posture; by using a cool diet ; bv avoiding ex- 
ternal heat ; and by obviating the irritation of hardened 
faeces by the use of proper laxatives, (949.) From what 
has been said above, as to the being careful not to increase 
the determination of the blood into the hemorrhoidal ves- 
sels, the propriety of these measures must sufficiently ap- 
pear ; and if they were not so generally neglected, many 
persons would escape the great trouble, and the various bad 
consequences, which so frequently re^It from this disease. 

956.] With respect to the further cure of this disease, 
it is almost in two cases only that hemorrhoidal persons 
call for the assistance of the physician. The one is when 
the affection is accompanied with much pain ; and of this 
there are two cases, according as the pain happens to at- 
tend the external or the internal piles. 

957.] The pain of the external piles arises especially 
when a considerable protrusion of the rectum has happened ; 
and when, continuing unreduced, it is strangled by the 
constriction of the sphincter ; while, at the same time, no 
bleeding happens, to take off the swelling of the protruded 
portion of the intestine. Sometimes an inflammation super- 
venes, and greatly aggravates the pain. To relieve the pain 
in this case, emollient fomentations and poultices are some- 
times of service ; but a more effectual relief is to be obtain- 
ed by applying leeches to the tumid parts. 

* It is doubtful whether riding is ever adviseabla in any period of the disease. Riding frt- 
quentlj- produces Pile*, m persons not in the least predisposed to them. 



PRACTICE OF PHYSIC. 299 

958.] The other case in which hemorrhoidal persons seek 
assistance, is that of excessive bleeding. Upon the opinion 
so generally received of this discharge being salutary, and 
from the observation that upon the discharge occurring per- 
sons have sometimes found relief from various disorders, 
the most part of persons liable to it are ready to let it go too 
far ; and indeed the Stahlians will not allow it to be a dis- 
ease, unless when it has actually gone to excess. I am, 
however, well persuaded, that this flux ought always to be 
cured as soon as possible. 

959.] When the disease occurs as a purely topical affec- 
tion, there can be nd doubt of the propriety of this rule ; 
and, even when it has occurred as a critical discharge in 
the case of a particular disease, yet when this disease shall 
have been entirely cured and removed, the preventing any 
return of the hemorrhois, seems to be both safe and proper. 

960.] It is only when the disease arises from a plethoric 
state of the body, and from a stagnation of blood in the hy- 
pochondriac region, or when, though originally topical, 
the disease, by frequent repetition, has become habitual, 
and has thereby acquired a connection with the whole sys- 
tem, that any doubt can arise as to the safety of curing it 
entirely. Even in these cases, however, I apprehend it 
will be always proper to moderate the bleeding ; lest by its 
continuance or repetition, the plethoric state of the body, 
and the particular determination of the blood into the he- 
morrhoidal vessels, be increased, and the recurrence of the 
disease, with all its inconveniences and danger, be too much 
favored. 

961.] Further, even in the cases stated (960.) in so far as 
the plethoric state of the body, and the tendency to that 
state, can be obviated and removed, this is always to be 
diligently attempted ; and if it can be executed with suc- 
cess, the flux may be entirely suppressed. 

962.] The Stahlian opinion, that the hemorrhoidal flux 
is only in excess when it occasions great debility, or a leu- 
cophlegmatia, is by no means just ; and it appears to me, 
that the smallest approach towards producing either of these, 
should be considered as an excess, which ought to be pre- 
vented from going farther. 

963.] In all cases therefore of excess, or of any approach 
towards it, and particularly when the disease depends upon 
a prolapsus ani, (950.) I am of opinion that astringents, both 
internal and external, may be safely and properly employ- 



300 PRACTICE OF PHYSIC. 

fed ; not indeed to induce an immediate and total suppres- 
sion, but to moderate the hemorrhagv, and by degrees to 
suppress it altogether, while at the same time measures are 
taken for removing the necessity of its recurrence. 

S64.J When the circumstances (945.) marking a con- 
nection between the hemorrhoidal affection and the state of 
the stomach occur, the measures necessary are the same as 
in the case of atonic gout. 



END OF THE FIRST VOLUME. 



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